When The Diabetic Child Is Hospitalized.
Since the management of diabetic children is primarily outpatient, and in most communities is quite excellent, we rarely see children admitted for minor regulation of their insulin doses or other more routine problems. Instead, we in the hospital rarely see diabetics is when they are first diagnosed - when their body's lack of insulin has not yet been recognized and their cells are essentially starving from lack of glucose. Theses kids are extremely ill and require aggressive and meticulous management to save them from irreversible coma and occasionally death.
The basic pathophysiology involves the starvation of the cells because of absent insulin and then the resulting extraordinarily high glucose in the blood stream, since it has not been transported effectively into the cells. This sets in motion several potentially injurious processes which, if left unchecked, will result in disaster.
When cells are deprived of glucose, they are forced to produce energy in alternative ways. This they do by breaking down other substances, namely fats and protein. Aside from the obvious effect this has on the body stores, leading to tremendous loss of body weight and muscle mass, the biochemical effects are more significant. The breakdown of fat leads to the production of ketones, or ketoacids, as byproducts. These have the effect of making the body's pH more acidic, resulting in an increased production of CO2 (carbon dioxide). The body deals with CO2 production by "blowing it off" during the exhalation phase of normal respiration. When acids are produced to such a degree as to overcome the body's ability to deal with them, they begin to poison other bodily functions, such as heart and brain function, leading to shock and coma.
Glucose, present in huge amounts in the bloodstream of the uncontrolled diabetic, acts as a diuretic by pulling water into the bloodstream and then out the kidneys leading to tremendous urinary losses and profound dehydration, further compounding shock and compromised vital functions.
The presentation of a child in the state we refer to as diabetic ketoacidosis, or DKA, is unforgettable and profound. First, the patient is severely dehydrated and often thin and wasted appearing. Fluid losses may be in the range of ten to fifteen percent of total body water which means these children may experience a ten to twenty percent weight loss just from dehydration alone.
If acidosis is severe enough, affected children breathe rapidly and deeply attempting to exhale the excess CO2. Often their breath smells fruity - a consequence of ketone body production. The child may be confused, incoherent or frankly unconscious and is often vomiting, which only adds to the severity and irreversibility of the dehydration.
This is a true pediatric emergency. First the airway must be stabilized if the child is comatose enough to prohibit adequate breathing. Then, the circulation must be reestablished and this is done by massive amounts of IV fluids. Often the body's electrolytes are also out of balance and these must be corrected carefully. To correct the underlying problem, and once circulation has been effectively normalized, insulin is administered, frequently in a low dose continuous infusion through the IV. The DKA crisis is considered averted when acidosis has been corrected and glucose is at a low enough level in the blood stream to no longer cause excessive loss of urine.
Once this goal has been achieved, and the child feels better than he has in weeks, he is ready to begin the lifelong education, training and treatment program that will result in a long, happy and hopefully complication free life.
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|Author:||Monaco, John E.|
|Publication:||Pediatrics for Parents|
|Date:||Jan 1, 1998|
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