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[IPp] Definition of DKA and how to know

According to a consensus by ISPAD (the International Society for Pediatric 
and Adolescent Diabetes) this is the definition of DKA.  It requires 3 
1.  Blood glucose greater than 12 mmol/L  (218)
2.  Large serum ketones -- acetone or betahydroxybutyrate 
3.  Acidosis--venous pH less than 7.3 or serum bicarbonate less than 15 

Occasionally DKA can occur with normoglycemia when there is vomiting.

These are the three (and only three) criteria for determing DKA.  The 
presentation can vary amongst patients as can other findings.  

Taken from Clinical Pediatrics 1996; 35, 261-266.

I am not surprised really that our pediatrician did not initially think that 
Claire was in DKA, for 2 reasons:
1.  you can't always tell just by looking at a patient; which is also the 
problem that us as parents face; and
2.  this doctor had never even seen an insulin pump until she met up with 
Claire last spring.  Thus she was totally unfamiliar with paediatric patients 
not on long-acting insulin, and didn't realize how fast you can go into DKA 
when you are using a pump.

The question I posed a couple of days ago, was how do we as parents know when 
it is only DK and when it is DKA.  Our subsequent discussion of the Precision 
Xtra meter helped me here.  I had never received any info with the meter 
about what the ketone readings actually meant (meter was sent to me directly 
from the company for free).  Also, I have never bought any of the ketone 
strips, as a kind person on the IP list sent me quite a number of ketone 
strips that she didn't want.  It is possible there is information in each 
box, I just haven't seen any of it.  So 2 days ago I looked up their web site 
and found that it quite clearly states that "a reading of 3.0 or greater on 
the meter is consistent with metabolic acidosis.  Strongly consider emergency 
intervention. "
     While I don't think we should rely on a home-use meter for making 
important medical decisions, I can say that the Precision Xtra meter gave us 
a ketone reading of  2.6 when Claire was feeling just fine, a reading of 3.2 
about 90 minutes later when we were leaving for the hospital and she was 
definately no longer fine, and 3.3 just over 2 hours after that.  (The Xtra 
meter measures Betahydroxybutyrate.)  Blood work taken just after that point 
showed her venous pH at 7.15, with normal being 7.35 to 7.45. 
     I didn't think that 7.15 was so much lower than 7.35 (we are all used to 
huge blood sugar swings), but the doctor assured me that small movements of 
this number are very important.  One would be much sicker at 7.1 and she said 
they would be really, really sick if the pH was 7.0. 
     Standard treatment for DKA involves 48 hours of IV therapy to rehydrate 
and reverse the acidosis, and of course to normalize bgs.  The acidosis takes 
awhile to improve.  The same article I quoted also says that if a patient can 
tolerate fluids, mild DKA (a pH greater than 7.25) can be treated without a 
hospital admission.  
     It doesn't surprise me that children dx with diabetes and who are in DKA 
at diagnosis are very, very sick.  They have likely been in a state of 
ketosis for quite awhile, perhaps off and on, and for an even longer period 
would have had bg swings up and down and been feeling pretty lousy.  Thus 
when it really hit them, their poor little bodies had already been battered 
for a long time.  
     In the weeks leading up to her dx, Claire as well would say to me 
"mommy, I'm too tired to walk" as she walked over to my chair for a cuddle 
and hug.  She had lost 10 percent of her weight, which is I think about the 
average weight loss at dx.  At age 2, that was only 3 pounds. Yet the day 
before her dx, she ran around like crazy chasing her brothers with a water 
pistol on our first warm sunny April day. (I had insisted on bringing in a 
urine sample the previous week when the doctor was away and I knew something 
was not right).  She obviously wasn't in DKA at diagnosis. 
     So I believe that this must be another YMMV situation--I don't think you 
can say that a child would be very, very sick to be in DKA and that you would 
definately know.  Your child could be in DKA and you treat it with insulin 
and fluids at home (if they can keep down fluids), just like they would do at 
the hospital and the child improves and you never even know that it happened. 
 But at least now I know that the 3.0 is the critical number on the Xtra 

Barbara, Mum of Claire 8  
> <<My daughter only had mild DKA (as defined by the level
> of acidosis) at dx and was so sick she couldn't even
> walk. I had to carry her to the ER (she was 6 and I was
> 9mos pg at the time). She also had a fruity odor on the
> breath which is another indicator (the type of ketones
> involved in DKA are exhaled via the lungs). Believe me,
> you'll know if it has become DKA! I guess you would
> have to see both to know the difference but I hope none
> of you ever have to. What we typically see at home is
> more of a pre-DKA state that without quick and
> aggressive action can quickly turn into DKA. Our endo
> told me that most people nowadays have never seen DKA
> and that even 70-80% of new dx are not in DKA. My
> suggestion is that as soon as you see the ketones
> forming, be very diligent and aggressive about giving
> extra insulin, hydration, and frequent bg and ketone
> checks. DKA happens when the DK hasn't been dealt with
> in a timely matter.
> I want to clarify the thing about vomiting. That
> doesn't mean it is DKA. The ketones will give you a
> stomach ache, make you feel nauseous and downright bad,
> and even make you vomit. Yes, they can appear very sick
> but with DKA (even mild) they are much, much sicker.
> What makes it DKA is the presence of acidosis, the
> degree of which determines if it is mild, moderate, or
> severe. Acidic blood is incompatible with life. Your
> daughter was probably teetering very close to DKA. Your
> dr probably didn't think it was DKA because pH alone
> isn't the defining/determining factor. There are other
> things (in the blood, and symptoms) that have to occur
> together to make the diagnosis. DKA typically takes
> days to turn around whereas what we treat at home
> typically takes hours.
> If you notice ketones and high bgs and the child is
> feeling very sick (and even vomits), and you treat it
> aggressively and you see it start to turn around within
> a few hours, it isn't DKA. But if, after a few hours it
> doesn't seem to be turning around and is maybe seeming
> worse than before, I'd say it is probably getting more
> serious and needs to be checked out. But you'll likely
> see it turning around before that point. Any time there
> is repeated vomiting (ie: they can't hold anything
> down) with the high bgs and ketones, it should be
> checked out. I wouldn't chance it.
> - --
> Take care, Kerri>>
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