Snap Shot A 12 year old boy, previously healthy, is admitted to the hospiral after 2 days of polyuria, polyphagia, nausea, vomting and abdominal pain. Temp is 37, BP 103/63, HR 112, RR 30. Physical exam shows a lethargic boy. Glucose is 534, Potasium is 5.9; WBC 16,000, pH is 7.13, PCO2 is 20 mmHg, PO2 is 90 mmHg. Introduction Results from absolute deficiency in insulin surge in counterregulatory homones (glucagon, growth hormone, catecholamine) results in hyperglycemia and ketonemia Most common in type I diabetes Precipitated by infections MI drugs (steroids, thiazide diuretics) noncompliance pancreatitis Presentation Symptoms vomiting abdominal pain Kussmaul Respiration (increased tidal volume) fruity, acetone odor severely dehydrated cerebral edema associated with high mortality in pediatric patients Evaluation Diagnostic criteria blood glucose levels > 250 mg/dL Arterial pH < 7.3 expect to see an increase in free calcium since the excess hydrogen displaces calcium from albumin Serum bicarbonate < 15mEq/L Moderate ketonuria and ketonemia Labs show: increased anion gap metabolic acidosis Treatment Fluids Insulin with glucose give insulin until ketones are gone, even after glucose normalizes or is below normal Replace potasium for hypokalemia caused by too much potassium being secreted in the urine as a result of the glucosuria labs may show pseudo-hyperkalemia due to transcellular shift of potassium out of the cells to balance the H being transfered into the cells give in the form of potassium phosphate rather than potasium chloride Aggresive electrolyte replacement give phosphate supplementation to prevent respiratory paralysis If mental status changes (headache, obtundation, coma) occur during treatment likely due to cerebral edema give mannitol Follow anion gap to monitor improvement