Suspected DKA in a child or adolescent
Under 18 years. Adults: use an adult DKA pathway. Pregnant: obstetric emergency; involve the obstetric team now (DKA can occur with glucose below 14 mmol/L). Follow PALS. Get paediatric specialist advice early.
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PediatricsEmergency
Pediatric Diabetic Ketoacidosis (ISPAD 2022)
Pediatric Diabetic Ketoacidosis (ISPAD 2022): Suspected DKA in a child or adolescent → Confirm DKA and grade severity → HHS or hyperosmolar DKA: do not ...
Pathway Overview
13 steps
Algorithm Steps
13 total
01Start 02Action Confirm DKA and grade severity
DKA = glucose >11 mmol/L, venous pH <7.3 or bicarbonate <18 mmol/L, and ketones (blood BOHB 3 mmol/L or more, or moderate or large urine ketones).
- Mild: pH <7.3 or bicarbonate <18 mmol/L
- Moderate: pH <7.2 or bicarbonate <10 mmol/L
- Severe: pH <7.1 or bicarbonate <5 mmol/L. Do not give bicarbonate to correct acidosis.
- Glucose can be near normal (euglycaemic DKA): fasting, low-carbohydrate diet, SGLT2 inhibitor or pregnancy. Start dextrose straight after the first fluid bolus.
- First tests: glucose, BOHB, venous gas, Na, K, Cl, urea, creatinine, Ca, Mg, phosphate, FBC. Calculate effective osmolality (2 x Na + glucose).
03Warning HHS or hyperosmolar DKA: do not use this DKA plan alone
Suspect HHS if glucose >33.3 mmol/L and effective osmolality >320 mOsm/kg with venous pH >7.25 and bicarbonate >15 mmol/L.
- HHS needs more fluid and later, lower-dose insulin than DKA
- Use an HHS protocol and get paediatric specialist advice now
- Mixed DKA and HHS: specialist advice; replace urine losses
04Action Emergency care and first fluid bolus
Shock: 0.9% saline 20 mL/kg as fast as possible, reassess after each bolus, repeat as needed. Start fluids before insulin.
- No shock but volume depleted: 0.9% saline 10-20 mL/kg IV over 20-30 min (20 mL/kg if perfusion is poor)
- Large or obese child: max 1 L per bolus
- High risk of cerebral injury (age <5 years, pH <7.1, pCO2 <21 mmHg, urea >7 mmol/L, new onset): HDU or PICU; calculate the mannitol or 3% saline dose and keep it at the bedside
- 2 IV cannulas. Weigh the child. Cardiac monitor. Oxygen if shock or poor circulation.
- Hourly HR, RR, BP and GCS from the start
- Low GCS without airway reflexes: secure the airway and pass an NG tube. Avoid intubation if possible: a rise in pCO2 can worsen brain injury.
- K result delayed: do an ECG to look for high or low K
- Avoid a central line unless essential (thrombosis risk)
05Action Deficit and maintenance fluids (after the bolus)
Give maintenance plus the deficit (minus bolus volume) evenly over 24-48 h. Do not restrict fluid if the child needs volume.
- Assume deficit: mild 5%, moderate 7%, severe 10% of body weight
- Deficit (mL) = % deficit x weight (kg) x 10
- Maintenance per day: 100 mL/kg for the first 10 kg, 50 mL/kg for the next 10 kg, 20 mL/kg for each kg above 20 kg
- Fluid: 0.45-0.9% saline or a balanced solution (Hartmann's, Plasma-Lyte 148), with potassium
- Subtract IV fluid given before arrival. Do not add urine losses routinely.
- Obese child: use actual weight; if the rate is above adult limits, use adult limits (max 500 mL/h)
- Na low and not rising as glucose falls: raise the sodium content of the fluid, not the rate
06Action Potassium: check K before insulin
Every child needs potassium, unless in renal failure. K falls fast once insulin starts.
- K below 3.5 mmol/L: give K with the first fluids on a separate line; defer insulin; cardiac monitor; senior advice
- K 3.5-5.5 mmol/L: start K after the first bolus, with insulin: 40 mmol/L in the fluid
- K above 5.5 mmol/L or no urine output: no K yet; recheck K every hour; start K when K is below 5.5 mmol/L and urine output is present
- Max K rate: 0.5 mmol/kg/h
- Use premixed potassium bags where possible. Do not add potassium to a bag that is already hanging.
- Give part as potassium phosphate, e.g., 20 mmol/L KCl + 20 mmol/L potassium phosphate
- Check K every 2-4 h (more often if abnormal). K stays low at max rate: lower the insulin rate.
- Phosphate below 0.32 mmol/L: treat now; check Ca and Mg during phosphate infusion
07Action Insulin infusion: start 1 h after IV fluids start
Only when K is 3.5 mmol/L or more. No IV insulin bolus. Do not stop insulin to treat falling glucose: add dextrose.
- Child: neutral (soluble) insulin, e.g., Actrapid, 0.05-0.1 units/kg/h IV (max 0.1 units/kg/h unless senior advice)
- pH above 7.15: 0.05 units/kg/h is usually enough (0.03 units/kg/h if age <5 years and mild DKA)
- Preparation: 50 units in 50 mL 0.9% saline (1 unit/mL). Prime the line with the insulin solution.
- Do not run insulin through a central line
- Keep the rate until DKA resolves. BOHB should fall by about 0.5 mmol/L per hour.
- No improvement in pH, anion gap or BOHB: check the infusion and preparation, look for infection, senior review
- IV access not possible: specialist advice on IM or SC insulin
08Warning Cerebral injury: treat on clinical signs; do not wait for CT
Most common in the first 12 h. Signs: new or worse headache or vomiting, heart rate falling (not from sleep or fluids), confusion, irritability, incontinence, cranial nerve palsy, abnormal posture or breathing, falling oxygen saturation. High BP alone is not a sign.
- Mannitol 0.5-1 g/kg IV over 10-15 min (20% mannitol = 2.5-5 mL/kg); may repeat after 30 min
- OR 3% saline 2.5-5 mL/kg IV over 10-15 min (also if no response to mannitol in 15-30 min)
- Nurse head up. Reduce the fluid rate (e.g., by one third) but keep BP normal. Call PICU. If intubated, do not let pCO2 fall below the level set by the acidosis.
09Decision Glucose 14-17 mmol/L or less, or falling >5 mmol/L/h?
Check hourly. Euglycaemic DKA: answer yes after the first bolus.
- If Yes
10Action Yes: add dextrose, keep insulin running
Add 5% dextrose to the saline and potassium fluid. Do not stop insulin.
- Keep insulin 0.05-0.1 units/kg/h until DKA resolves
- Glucose falling fast (>5 mmol/L/h) or below 5 mmol/L: change to 10% (or 12.5%) dextrose
- Glucose below 4 mmol/L: 10% glucose 2 mL/kg IV bolus, repeat if needed; change fluids to 10% glucose. Do not stop insulin.
- Glucose stays low on 10% glucose: lower the insulin rate (e.g., 0.1 to 0.05 units/kg/h), only if the acidosis is still resolving
11Action Monitor until DKA resolves
Record hourly on a flow chart. Find and treat the cause (missed insulin, pump failure, infection, new diabetes).
- Hourly: HR, RR, BP, GCS, capillary glucose (check against lab glucose), insulin given, fluid in and out
- Every 2-4 h: Na, K, Cl, glucose, urea, Ca, Mg, phosphate, venous gas, BOHB
- No bicarbonate, except for life-threatening high K or pH <6.9 with poor cardiac contractility
- Anion gap = Na - (Cl + HCO3); normal 12 +/- 2 mmol/L. Above 35 mmol/L: think of lactic acidosis.
- Corrected Na = Na + 1.6 x (glucose - 5.6) / 5.6 (mmol/L). Measured Na should rise as glucose falls.
- Acidosis persists with a closed anion gap: usually high chloride; not a reason to delay SC insulin
- Weigh every morning
12Outcome DKA resolved: change to SC insulin
Resolved: pH >7.30, bicarbonate >18 mmol/L, BOHB <1 mmol/L or anion gap closed. Give SC rapid-acting insulin 15-30 min before stopping IV insulin.
- Do not use urine ketones to judge resolution (they persist for hours)
- Start SC insulin when DKA has resolved and the child can eat and drink, ideally just before a meal
- Give basal insulin too. Basal insulin needs a longer overlap with the infusion.
- Check glucose often after the change. Give diabetes education and a plan to prevent another episode.
If No13Action No: continue fluids without dextrose
Glucose above 14-17 mmol/L. Check glucose every hour and add 5% dextrose when it reaches this level.
- Path rejoins step 11Shared downstream outcome
Guideline Source
ISPAD Clinical Practice Consensus Guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- HHS and mixed DKA-HHS need a separate HHS protocol and specialist advice.
- For children and adolescents under 18 years. Local paediatric DKA protocols (e.g., RCH Melbourne) differ in small details; follow your hospital protocol where it differs.
- Deficit estimates (5%, 7%, 10%) are assumptions; reassess circulation and fluid balance often.
- Does not cover SC-only insulin protocols for low-resource settings.
Contraindicated Populations
Adults 18 years and over (use an adult DKA pathway)
Applicable Regions
AUUSEUUKNZ
AU: Units are mmol/L. RCH Melbourne DKA guideline (Jul 2025): insulin 0.1 units/kg/h (0.05 if age <5 y, transfer or glucose <15 mmol/L); defer insulin if K <3.0 mmol/L; 5% glucose at glucose 15 mmol/L or less; mannitol 20% 0.5 g/kg over 20 min or 3% saline 3 mL/kg over 15 min. Use premixed potassium bags; do not add K to hanging bags.
US: US labs report glucose in mg/dL (11 mmol/L = 200 mg/dL; 14-17 mmol/L = 250-300 mg/dL) and BUN (urea 7 mmol/L = BUN 20 mg/dL). Regular insulin = neutral soluble insulin.
Version 2Next review: 2027-09-30
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Frequently Asked Questions
What is the Pediatric Diabetic Ketoacidosis (ISPAD 2022)?
The Pediatric Diabetic Ketoacidosis (ISPAD 2022) is a emergency clinical algorithm for Pediatrics. It provides a structured decision tree to guide clinical decision-making, based on ISPAD Clinical Practice Consensus Guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state.
What guideline is the Pediatric Diabetic Ketoacidosis (ISPAD 2022) based on?
This algorithm is based on ISPAD Clinical Practice Consensus Guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state (DOI: 10.1111/pedi.13406).
What are the limitations of the Pediatric Diabetic Ketoacidosis (ISPAD 2022)?
Known limitations include: HHS and mixed DKA-HHS need a separate HHS protocol and specialist advice.; For children and adolescents under 18 years. Local paediatric DKA protocols (e.g., RCH Melbourne) differ in small details; follow your hospital protocol where it differs.; Deficit estimates (5%, 7%, 10%) are assumptions; reassess circulation and fluid balance often.; Does not cover SC-only insulin protocols for low-resource settings.. Individual patient factors may require deviation from these recommendations.
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