Pediatric Diabetic Ketoacidosis (ISPAD 2022)

Algorithm Steps

1. ▶

   Start

   Suspected Pediatric DKA

   Child with hyperglycemia, ketosis, and acidosis

   1. ●

      Action

      Confirm DKA Diagnosis

      Laboratory criteria for DKA

      • Blood glucose >200 mg/dL (11 mmol/L)
      • Venous pH <7.3 or HCO3 <18 mmol/L
      • Ketonemia or ketonuria
      • SEVERITY:
      • • Mild: pH 7.2-7.3, HCO3 10-18
      • • Moderate: pH 7.1-7.2, HCO3 5-10
      • • Severe: pH <7.1, HCO3 <5
      1. ●

         Action

         Initial Resuscitation

         Stabilize circulation and begin monitoring

         • Obtain IV access x2 (labs + fluids)
         • Weigh patient (use actual weight for calculations)
         • Assess degree of dehydration (5-10%)
         • If SHOCK: NS 10-20 mL/kg bolus over 20-60 min
         • May repeat to restore perfusion (max ~30 mL/kg in first hour)
         • Start monitoring: Neuro checks q1h, vitals, I/O
         • Insert Foley if impaired consciousness
         1. ●

            Action

            Fluid Replacement (Hours 1-2)

            Careful rehydration to avoid cerebral edema

            • Calculate fluid deficit: Weight × % dehydration × 10
            • Replace deficit over 24-48 hours (not faster)
            • Initial rate: ~1.5-2× maintenance
            • Use NS or balanced solution initially
            • Switch to NS with K+ once urinating
            • DO NOT exceed 1.5-2× maintenance rate
            1. ●

               Action

               Insulin Infusion

               Start 1-2 hours after fluid resuscitation begins

               • Regular insulin: 0.05-0.1 units/kg/hr IV
               • Start AFTER initial fluid bolus (1-2 hr delay)
               • DO NOT give insulin bolus in children
               • Target glucose decrease: 50-90 mg/dL/hr
               • If glucose falling faster, increase dextrose
               • Maintain infusion until ketosis resolves (pH >7.3, HCO3 >18)
               1. ◆

                  Decision

                  Glucose <250-300 mg/dL?

                  Add dextrose when glucose falls

                  1. ●

                     Action

                     Add Dextrose to Fluids

                     Maintain glucose while continuing insulin

                     • Change to D5-NS or D10-NS
                     • Continue insulin infusion
                     • Goal: Maintain glucose 150-250 mg/dL
                     • Continue until ketosis resolves
                     • Do NOT stop insulin until gap closed
                     1. ●

                        Action

                        Ongoing Monitoring

                        Frequent reassessment required

                        • Glucose: hourly
                        • Electrolytes, BUN, pH: every 2-4 hours
                        • Neuro checks: hourly for first 12 hours
                        • I/O: strict monitoring
                        • Calculate anion gap (closes before HCO3 normalizes)
                        1. ✓

                           Outcome

                           DKA Resolved

                           Transition to subcutaneous insulin

                           • Resolution criteria: pH >7.3, HCO3 >18, anion gap normal, tolerating PO
                           • Give SC insulin 15-30 min before stopping IV insulin
                           • Transition to age-appropriate insulin regimen
                           • Diabetes education before discharge
               2. ⚠

                  Warning

                  ⚠️ CEREBRAL EDEMA

                  Watch for neurologic deterioration

                  • RISK FACTORS: Age <5, new-onset, severe acidosis, rapid correction
                  • SIGNS: Headache, altered mental status, bradycardia, hypertension
                  • Cushing triad, posturing, pupil changes
                  • TREATMENT:
                  • • Elevate head of bed 30°
                  • • Reduce fluid rate by 1/3
                  • • Mannitol 0.5-1 g/kg IV over 20 min
                  • • OR Hypertonic saline 3% 2.5-5 mL/kg over 15-30 min
                  • • Intubate if needed (avoid hypocapnia)
            2. ●

               Action

               Potassium Replacement

               Critical - K+ drops with insulin/pH correction

               • Add K+ to fluids once K+ <5.5 and urinating
               • K+ 4.5-5.5: 20 mEq/L
               • K+ 3.5-4.5: 40 mEq/L
               • K+ <3.5: 40-60 mEq/L (delay insulin if <3)
               • Use KCl + K-phosphate (or K-acetate)
               • Check K+ every 2-4 hours