Managing diabetic ketoacidosis in special conditions: Difficulties and dilemmas

Table 1 Key management principles of management of diabetic ketoacidosis in different co-morbid conditions

Disease	Key management principles
DKA with chronic kidney disease	Routine bolus fluid replacement is not needed in euvolemic patients
	In patients with hypovolemia, small aliquot of 250 mL i.v. fluid should be given slowly
	In severe hypervolemia with refractory pulmonary oedema, hemodialysis may be needed
	Lower dose of fixed rate intravenous insulin infusion (0.05 units/kg/hour) is preferred in ESRD patients
	Routine supplementation of potassium is not recommended
	In case of severe hyperkalemia (> 6.5 mmol/L), hemodialysis may even be required
	Bicarbonate therapy can rarely be required in pre-existing chronic metabolic acidosis (pH < 7.2) after nephrology consultation
DKA with heart failure	Strict advanced hemodynamic monitoring is needed for assessment of volume status
	Cautious and slow replacement of minimal fluid bolus (250-500 mL) at a time, only if required
	Concentrated dextrose infusion may be needed (25%dextrose) in patients with hypervolemia
	Persistent hypotension can be due to HF and will require administration of vasoactive agents
	Treatment of precipitating factors including any cardiac events
	Modifications of chronic medications (discontinuation SGLT2i)
DKA with acute pancreatitis	Early initiation of fluid replacement and intravenous insulin infusion
	Early diagnosis and prompt initiation of management of acute pancreatitis
	Use of intravenous insulin infusion will also help reduce concomitant hypertriglyceridemia, if any

DKA: Diabetic ketoacidosis; ESRD: End stage renal disease; i.v.: Intravenous; SGLT2i: Sodium-glucose cotransporter-2 inhibitors; HF: Heart failure.

Table 2 Comparison of major pediatric diabetic ketoacidosis management guidelines from different countries

Management aspects	ISPAD Guidelines	BSPED (United Kingdom)	CPS (Canada)
Fluid therapy (initial bolus)	Recommends 0.45% or 0.9% NaCl or balanced salt solutions. Infuse fluids (10 mL/kg) over 30-60 minutes for those not in shock; may repeat1	Infuse 10 mL/kg bolus over 60 minutes to all patients managed with i.v. fluids (not in shock)	Administer 10-20 mL/kg (to a maximum 1000 mL) of isotonic fluid with 0.9% NaCl or a balanced crystalloid for all patients over 20-30 minutes
Insulin administration	Continuous insulin infusion at 0.05-0.1 unit/kg/hour starting 1 hour after fluids initiated (0.05 units/kg/hour for mild DKA)	Rate of 0.1 units/kg/hour	Rate of 0.05-0.1 units/kg/hour similar to ISPAD but recommends decreasing to 0.025 units/kg/hour if BG falls rapidly or as a bridge to s.c. insulin
Electrolyte management	Start replacing potassium after initial volume expansion and concurrent with starting insulin therapy2; The starting potassium concentration in the infusate should be 40 mmol/L	Use 0.9% NaCl with 20 mmol KCl in 500 mL (or 40 mmol in a L)	Supplemental potassium of at least 40 mmol/L should be added to i.v. fluids when potassium is < 5 mmol/L and after recent urine output is documented
Glucose introduction	Suggests adding 5% dextrose before glucose levels fall to 17 mmol/L if dropping rapidly or at 14-17 mmol/L	Use glucose-containing fluids once plasma glucose drops to < 14 mmol/L	Dextrose (usually 5%) should be added when glucose level is between 15 and 17 mmol/L.

¹Fluid resuscitation during shock - 20 mL/kg 0.9% NaCl intravenous bolus, which is not subtracted from the total fluid deficit.

²If potassium is given with the initial rapid volume expansion, a concentration of 20 mmol/L should be used.

BSPED: British Society for Paediatric Endocrinology and Diabetes; CPS: Canadian Paediatric Society; DKA: Diabetic ketoacidosis; ISPAD: International Society for Pediatric and Adolescent Diabetes; i.v.: Intravenous; s.c.: Subcutaneous.

Table 3 Key management principles of management of atypical forms of diabetic ketoacidosis

Disease	Key management principles
euDKA	Physicians should have heightened awareness of this nuanced presentation of euDKA
	To minimize the risk of euDKA associated with SGLT-2 inhibitors, the recommendations from international societies should be followed
	To have a low threshold for obtaining ketone levels in diabetic patients with unexplained acidosis, even in absence of significant hyperglycemia
	Insulin dose reduction should be achieved by slow, gentle decrements simultaneously to avoid hypoglycemia and sliding toward euDKA
	Dextrose containing fluids should be used early in these patients to avoid hypoglycemia due to insulin infusion
	In case of euDKA in non-diabetic individuals, insulin infusion is not necessary, whereas fluid replacement and intravenous glucose solution are sufficient for the resolution of acidosis
Diabetic ketoacidosis and hyperosmolar hyperglycemic state overlap	Aggressive hydration is needed in first 12 hours to maintain a positive fluid balance (like management of HHS)
	Higher dose of fixed rate intravenous insulin infusion (0.1 units/kg/hour) is preferred (like management of DKA)
	Early initiation of insulin infusion along with i.v. fluid therapy (like management of DKA)
	Frequent monitoring of serum potassium should be done along with routine supplementation of potassium
	Identification and management of precipitating causes

DKA: Diabetic ketoacidosis; HHS: Hyperosmolar hyperglycemic state; i.v.: Intravenous; euDKA: Euglycemic diabetic ketoacidosis; SGLT-2: Sodium-glucose cotransporter-2 inhibitors.