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In January 2020, the British Society for Paediatric Endocrinology and Diabetes (BSPED) published an interim guideline for the management of diabetic ketoacidosis (DKA), which replaces the 2015 guideline. There have been substantial changes due to controversies in DKA management, particularly relating to the risk of cerebral oedema.
Paediatric DKA is a common presentation in type 1 diabetes accounting for 2700 admissions in the UK per year. Of these, approximately 25% occur in those with a new diagnosis of DKA.1 The main complications include cerebral oedema, thrombosis, acute kidney injury and electrolyte imbalance. Cerebral oedema occurs in around 1% of cases of DKA, but as many as 13% of patients receive treatment for suspected cerebral oedema due to difficulty in diagnosis. 1 2 Traditionally, cerebral oedema was attributed to fluid shifts after rapid changes in osmolality, but more recently, a multifactorial pathogenesis including vasogenic and cytotoxic oedema has been accepted with implications for management.3 4
Guidelines on management of paediatric DKA have been produced by National Institute for Clinical Excellence (NICE) (NG18 produced 2015)5 and The International Society for Paediatric and Adolescent Diabetes (ISPAD), which produced their latest guideline in 2018.6 The NICE guidelines are due to be updated in 2020–2021, and the BSPED 2020 guideline is considered an interim guideline pending this review. The expectation is that they will make suggestions in line with those within this guideline.
Diagnosis and risk stratification
The definition of DKA is acidosis (pH<7.3 or bicarbonate<15 mmol/L) with ketonaemia (ketones greater than 3 mmol/L) or ketonuria. This differs from the previous cut-off (bicarbonate<18 mmol/L) aligning with ISPAD definitions.
The severity of DKA is stratified in three groups: mild, moderate and severe (box 1).
Severity of diabetic ketoacidosis
Mild: venous pH 7.2–7.29 or bicarbonate<15 mmol/L. Assume 5% dehydration.
Moderate: venous pH 7.1–7.19 or bicarbonate<10 mmol/L. Assume 7% dehydration.
Severe: venous pH<7.1 or bicarbonate<5 mmol/L. Assume 10% dehydration. …
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Commissioned; externally peer reviewed.