**4.2. Diagnosis of DKA**

Although DKA is defined by the biochemical triad of ketonemia, hyperglycemia and acide‐ mia, several exceptions do exist which may provide a diagnostic dilemma for the physician in the emergency room. Examples of such are:

may be increased to levels consistent with DKA when a urine ketone test is negative or

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**◦** High doses of Vitamin C may cause false-negative results, while some drugs may, on

Management of DKA should be mainly directed to correction of acidosis. Immediate aims of

**•** Access to laboratories that can provide frequent and timely measurements of biochemical

**•** A specialist/consultant pediatrician experienced in the management of DKA should su‐

Children with severe DKA or those at high risk for cerebral edema should be treated in an intensive care unit (pediatric, if available) or in a unit that has equivalent resources and su‐

In a child with established diabetes, whose parents have been trained in sick day manage‐ ment, and who presents with mild DKA, can be managed in an outpatient health care facili‐ ty (e.g., emergency ward), provided an experienced diabetes team supervises the care [15].

**•** Clinically evaluate the patient to confirm the diagnosis and determine its cause. Carefully

shows only trace or small ketonuria

**5. Management of DKA**

**5.1. Goals of therapy**

management include [1,4]:

**•** Initiation of Insulin therapy

**5.2. Place of management**

*Emergency Assessment [23]*

look for evidence of infection.

**•** Assess level of consciousness

variables

**•** Expansion of the intravascular volume

**•** Assessment and monitoring of therapy

**•** Written guidelines for DKA management

pervise inpatient management [4].

**•** Correction of deficit in fluids, electrolyte & acid base status

The child with DKA should receive care in a unit that has: **•** Experienced nursing staff trained in DKA management

pervision, such as a children's ward specializing in diabetes care [4].

the other hand, give false-positive results.

**◦** The readings are qualitative depending on color comparisons

	- **◦** plasma glucose concentration >33.3 mmol/L (600 mg/dL)
	- **◦** arterial pH >7.30
	- **◦** serum bicarbonate >15 mmol/L
	- **◦** small ketonuria, absent to mild ketonemia
	- **◦** effective serum osmolality >320 mOsm/kg
	- **◦** stupor or coma

It is important to recognize that overlap between the characteristic features of HHS and DKA may occur. Some patients with HHS, especially when there is very severe dehydration, have mild or moderate acidosis. Conversely, some children with T1DM may have features of HHS (severe hyperglycemia) if high carbohydrate containing beverages have been used to quench thirst and replace urinary losses prior to diagnosis [22].

	- **◦** Polyuria, polydipsia and weight loss which are characteristic features of diabetes are difficult to demonstrate in the very young.
	- **◦** up to 70% of the young have DKA as a first presentation, hence, at presentation, dura‐ tion of DKA is usually longer, dehydration and acidosis are more severe, as young chil‐ dren have relatively higher basal metabolic rate, and a relatively large surface area relative to body mass.
	- **◦** The used method does not detect the major ketone body B-hydroxybutyrate. (sodium nitroprusside only measures acetoacetate and acetone). Serum ß-OHB concentrations,

may be increased to levels consistent with DKA when a urine ketone test is negative or shows only trace or small ketonuria

