ISPAD 2022-based management of DKA in children and adolescents: severity, cautious fluid deficit replacement over 24–48 h, insulin 0.05–0.1 unit/kg/h without bolus, potassium rules, the two-bag dextrose approach and recognising and treating cerebral oedema.
At the bedside
Timed steps- 1
Confirm and grade
0DKA = glucose >11 mmol/L (>200 mg/dL) + venous pH <7.3 or HCO₃⁻ <18 mmol/L + ketonaemia (β-hydroxybutyrate ≥3 mmol/L) or moderate/large ketonuria. Mild: pH <7.3 or HCO₃⁻ <18; moderate: pH <7.2 or HCO₃⁻ <10; severe: pH <7.1 or HCO₃⁻ <5. Weigh the child.
- 2
Resuscitate only if shocked
0–30 minShock (weak pulses, hypotension, CRT >3 s): 0.9% saline 20 mL/kg rapidly, repeat as needed. No shock but dehydrated: 10–20 mL/kg 0.9% saline over 20–30 min.
- 3
Deficit + maintenance
0–48 hEstimate deficit (moderate DKA ~5–7%, severe ~7–10% of body weight) and replace evenly over 24–48 h plus maintenance, using 0.45–0.9% saline or a balanced crystalloid with potassium. Avoid exceeding ~1.5–2 × maintenance in most children.
- 4
Insulin infusion — no bolus
+1 hStart regular insulin 0.05–0.1 unit/kg/h at least 1 h after starting fluids (0.05 unit/kg/h in young children or mild DKA is reasonable). Do not reduce below 0.05 unit/kg/h until acidosis resolves; add dextrose instead.
- 5
Potassium
With insulinHypokalaemic: add potassium from the start (with initial volume expansion), before insulin. Normal K⁺: add potassium when insulin starts. Hyperkalaemic: wait until urine output is documented. Usually 40 mmol/L (20 mmol/L if rate >10 mL/kg/h); keep ≤0.5 mmol/kg/h.
- 6
Add dextrose
Glucose ≤14–17 mmol/LWhen glucose falls to ~14–17 mmol/L (250–300 mg/dL) or drops faster than 5 mmol/L/h: add 5% dextrose (up to 10–12.5%) to keep glucose 8–12 mmol/L (145–220 mg/dL) while insulin clears ketones.
- 7
Monitor
HourlyHourly glucose, vitals, neurological observations (headache, behaviour, GCS) and fluid balance; venous gas, electrolytes and ketones every 2–4 h. Corrected sodium should rise as glucose falls — a falling corrected Na⁺ is a warning sign.
- 8
Switch to subcutaneous insulin
ResolutionResolved when pH >7.30, HCO₃⁻ >18 mmol/L and β-hydroxybutyrate <1 mmol/L, tolerating oral intake. Give SC rapid-acting insulin 15–30 min (regular 1–2 h) before stopping the infusion; start basal insulin.
DKA insulin infusion (no bolus)
Regular (soluble) insulin — paediatric DKA
- Dose
- 0.05–0.1 unit/kg/h, from ≥1 h after starting fluids
- Range
- 0.05–0.1 units/kg/h
- Preparation
- 50 units regular insulin in 50 mL 0.9% saline = 1 unit/mL (prime the line)
- Worked example
- 20 kg at 0.1 unit/kg/h = 2 units/h = 2 mL/h; at 0.05 unit/kg/h = 1 mL/h.
Initial fluid (dehydrated, not shocked)
Balanced crystalloid / 0.9% saline bolus — paediatric
- Dose
- 10–20 mL/kg 0.9% saline over 20–30 min (20 mL/kg rapidly if shocked)
- Worked example
- 20 kg: 200–400 mL over 20–30 min.
Potassium replacement
Potassium chloride (in IV fluids) — paediatric DKA
- Dose
- 40 mmol/L in replacement fluid (20 mmol/L if fluid >10 mL/kg/h); ≤0.5 mmol/kg/h
- Worked example
- 20 kg at 90 mL/h with 40 mmol/L = 3.6 mmol/h (0.18 mmol/kg/h).
Cerebral oedema
Mannitol — paediatric
- Dose
- 0.5–1 g/kg over 10–15 min; repeat after 30 min if no response
- Worked example
- 20 kg: 10–20 g = 50–100 mL of 20% mannitol.
Cerebral oedema (alternative)
Hypertonic saline 3% — paediatric
- Dose
- 2.5–5 mL/kg of 3% NaCl over 10–15 min
- Worked example
- 20 kg: 50–100 mL of 3% saline.
Worked fluid example: 20 kg child, moderate DKA (~7% deficit), not shocked
| Component | Calculation | Result |
|---|---|---|
| Deficit | 20 kg × 7% = 1.4 kg | 1,400 mL |
| Maintenance (Holliday–Segar) | 40 + 20 = 60 mL/h × 48 h | 2,880 mL |
| Total over 48 h | 1,400 + 2,880 | 4,280 mL |
| Hourly rate | 4,280 ÷ 48 | ≈ 89 mL/h |
Many units subtract an initial 10–20 mL/kg bolus from the total and replace over 24–48 h; follow the local protocol. Recalculate if weight or clinical status changes.
When to start potassium
| Initial K⁺ | Action |
|---|---|
| <3.5 mmol/L (hypokalaemia) | Add K⁺ to initial expansion fluid; delay insulin if <3 mmol/L until K⁺ given |
| 3.5–5.5 mmol/L | Add 40 mmol/L when insulin starts |
| >5.5 mmol/L | Wait until urine output documented and K⁺ falling |
Calculators for this topic
Infusion rate from per-kg-per-hour dose
Pump rate for drugs dosed per kg per hour (insulin U/kg/h, midazolam mg/kg/h, propofol mg/kg/h, fentanyl mcg/kg/h, dexmedetomidine mcg/kg/h).
Sodium corrected for glucose
Na + 2.4 × (glucose − 100)/100 (Hillier; Katz uses 1.6).
Anion gap
Na⁺ − (Cl⁻ + HCO₃⁻). Correct for albumin.
Calculated serum osmolality (Indian units)
2 × Na + glucose (mg/dL)/18 + urea (mg/dL)/6. Uses blood urea, as reported by most Indian labs.
References
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Paediatric DKA — first hours
Step 1 of ~8
ISPAD 2022-based pathway.
Decision: Shocked?
Based on Glaser N, Fritsch M, Priyambada L, et al. Educational use; follow local protocol.
Pathophysiology
Insulin deficiency and glucagon excess drive hepatic gluconeogenesis and lipolysis → ketone production (β-hydroxybutyrate > acetoacetate) and high anion gap acidosis. Osmotic diuresis depletes water, sodium, potassium and phosphate; serum K⁺ may be normal or high despite total-body depletion because of acidosis and insulin lack. Cerebral oedema is now thought to relate more to cerebral hypoperfusion and neuroinflammation during the illness than simply to fluid rate.
Evidence
- ISPAD 2022 consensus: biochemical definition and severity grading; fluid deficit replacement over 24–48 h; insulin 0.05–0.1 unit/kg/h from ≥1 h after fluids; potassium timing by initial K⁺; avoid bicarbonate except in specific situations; mannitol or hypertonic saline for cerebral oedema.
- PECARN FLUID (Kuppermann, NEJM 2018): 2×2 factorial RCT (faster vs slower; 0.9% vs 0.45% saline); no significant difference in GCS decline (<14) or clinically apparent brain injury; short-term memory similar. Supports moderately liberal, isotonic-to-half-normal fluids with monitoring.
- Cerebral oedema occurs in roughly 0.5–1% of paediatric DKA episodes with substantial mortality; subclinical oedema is common on imaging.
Controversies
- Insulin 0.05 vs 0.1 unit/kg/h (similar efficacy in small trials; 0.05 suits young children).
- 0.9% saline vs balanced crystalloids (hyperchloraemic acidosis can delay apparent resolution of HCO₃⁻).
- Subtracting resuscitation boluses from total fluid.
🇮🇳 India notes
- DKA is frequently the first presentation of type 1 diabetes in Indian children, often after misdiagnosis as gastroenteritis, pneumonia or acute abdomen; check glucose in every sick, vomiting, breathless child.
- Blood ketone meters are not universal; urine ketones and anion gap are acceptable surrogates, but urine ketones lag behind clearance.
- Many wards lack infusion pumps — paediatric DKA should be managed in an HDU/PICU with syringe drivers; if transfer is needed, start fluids and insulin per protocol before transfer and send the flow chart.
- Insulin is supplied as 40 units/mL (vials) and 100 units/mL (pens/vials) in India — confirm the strength before drawing up to avoid 2.5-fold errors.
References
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