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Approximately 25 per cent of children present in diabetic ketoacidosis at diagnosis of type 1 diabetes, and this remains a life-threatening condition.

Guidelines for treatment are necessary, although they must always be tailored to the individual. Resuscitation is the primary objective. This includes prevention of aspiration of gastric contents using a nasogastric tube and adequate - but not excessive - replacement of circulating volume.

Further management comprises replacement of fluids with 0.9 per cent saline, replacement of potassium losses and the institution of insulin using a continuous intravenous infusion.

Recovery is usually straightforward, but there is still a significant mortality and morbidity, largely arising from the unpredictable

Emergencies in Diabetes Edited by Andrew J. Krentz © 2004 John Wiley & Sons, Ltd ISBN 0-471-49814-9

complication of cerebral oedema. The pathophysiology of this devastating condition is still unknown, and there is an ongoing debate as to whether it is related to the treatment received. It is prudent to ensure that changes in osmolality do not occur too quickly, and that rehydration is not excessive. However, until the cause of cerebral oedema is known, no guidelines can be considered completely infallible. Close supervision from senior members of staff is essential, and there should be early concern if progress is not as predicted.

Early assessment of the best place to nurse the child should be made, and clear instructions given to nursing staff for frequent monitoring of vital signs and neurological observations. Headache and behaviour change should be reported at any time to medical staff. Rapid intervention with intravenous mannitol and immediate transfer to an intensive care unit for assisted hyperventilation and additional support is necessary if signs of cerebral oedema develop.

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