DKA is a severe metabolic derangement characterized by dehydration, loss of electrolytes, hyperglycemia, hyperketonemia, acidosis and progressive loss of consciousness that results from severe insulin deficiency combined with the effects of increased levels of counterregulatory hormones (catecholamines, glucagon, cortisol, growth hormone). The biochemical criteria for diagnosis are: blood glucose > 200 mg/dl, venous pH <7.3 or bicarbonate <15 mEq/L, ketonemia >3 mmol/L and presence of ketonuria. A patient with DKA must be managed in an emergency ward by an experienced staff or in an intensive care unit (ICU), in order to provide an intensive monitoring of the vital and neurological signs, and of the patient's clinical and biochemical response to treatment. DKA treatment guidelines include: restoration of circulating volume and electrolyte replacement; correction of insulin deficiency aiming at the resolution of metabolic acidosis and ketosis; reduction of risk of cerebral edema; avoidance of other complications of therapy (hypoglycemia, hypokalemia, hyperkalemia, hyperchloremic acidosis); identification and treatment of precipitating events. In Brazil, there are few pediatric ICU beds in public hospitals, so an alternative protocol was designed to abbreviate the time on intravenous infusion lines in order to facilitate DKA management in general emergency wards. The main differences between this protocol and the international guidelines are: intravenous fluid will be stopped when oral fluids are well tolerated and total deficit will be replaced orally; if potassium analysis still indicate need for replacement, it will be given orally; subcutaneous rapid-acting insulin analog is administered at 0.15 U/kg dose every 2-3 hours until resolution of metabolic acidosis; approximately 12 hours after treatment initiation, intermediate-acting (NPH) insulin is initiated at the dose of 0.6-1 U/kg/day, and it will be lowered to 0.4-0.7 U/kg/day at discharge from hospital.
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机译：DKA是一种严重的代谢紊乱，其特征是脱水，失去电解质，高血糖，高酮血症，酸中毒和进行性意识丧失，这是由于严重的胰岛素缺乏症以及反调节激素（儿茶酚胺，胰高血糖素，皮质醇，生长激素）水平升高所致。诊断的生化标准是：血糖> 200 mg / dl，静脉pH <7.3或碳酸氢盐<15 mEq / L，酮血症> 3 mmol / L，并存在酮尿症。 DKA患者必须在急诊室由经验丰富的工作人员或重症监护病房（ICU）进行管理，以便对生命和神经体征以及患者对治疗的临床和生化反应进行深入监控。 DKA治疗指南包括：恢复循环量和更换电解质；纠正胰岛素缺乏症，以解决代谢性酸中毒和酮症；减少脑水肿的风险；避免其他治疗并发症（低血糖，低血钾，高血钾，高氯酸中毒）；识别和处理突发事件。在巴西，公立医院的儿科ICU病床很少，因此设计了一种替代方案来缩短静脉输液管线的时间，以便于在普通急诊室进行DKA管理。该协议与国际准则之间的主要区别在于：如果对口服液的耐受性良好，将停止静脉注射液，并且将通过口服方式补充全部不足；如果钾分析仍然表明需要更换，将口服。每2-3小时以0.15 U / kg的剂量给药皮下速效胰岛素类似物，直至代谢性酸中毒消失为止；在治疗开始后约12小时，以0.6-1 U / kg /天的剂量开始使用中效（NPH）胰岛素，出院时将降低至0.4-0.7 U / kg /天。
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