Diabetic Ketoacidosis (DKA)

Diabetic ketoacidosis (DKA) is a serious complication of new-onset or existing Type 1 or Type 2 diabetes. Dehydration and metabolic derangements associated with DKA are treated with liberal fluid resuscitation, insulin infusion, and close monitoring of neurological, metabolic, and fluid status. Episodes of pediatric DKA must be treated according to a pediatric-specific protocol (refer to TREKK’s Pediatric DKA Algorithm) in close communication with a pediatric diabetes specialist.

• Diabetes (either new-onset or existing): random blood glucose of >11 mmol/L AND
• Acidosis: pH <7.3 or HCO₃ <18 mmol/L on venous or capillary blood gas AND
• Ketonuria/ketonemia: moderate/large urine ketones or serum beta-hydroxybutyrate ≥3 mmol/L

• Evaluate airway, breathing, circulation, level of consciousness, and signs of dehydration.
• Reassess ABCDs and vital signs frequently, as clinical condition can rapidly change.
• Obtain history of oral intake, urine output, weight loss, headache, nausea, vomiting, abdominal pain, weakness, and additional health conditions and medications.
• Ask about precipitating factors: intercurrent illness, adherence to insulin regimen in patients with known diabetes, new medications, pregnancy.
• Urgent laboratory investigations should include:
  • • Blood glucose, venous blood gas, Na, K, Cl, (Ca, PO₄, if available), urea, creatinine, osmolality, serum or urine ketones

• Up to 1% of episodes of pediatric DKA may be complicated by significant cerebral injury (CI) associated with high morbidity and mortality.1 Additionally, evidence suggests that pediatric patients may experience both subclinical CI as well as long-term cognitive sequelae.^2,3
• There is NO difference in the incidence of CI between pediatric DKA patients treated with a standard or rapid fluid resuscitation protocol using isotonic or hypotonic IV fluid.⁴

IDENTIFY PATIENTS AT RISK FOR CEREBRAL INJURY:

• Greater acidosis (↓pH), hypocapnia (pCO₂<18)
• Longer duration of symptoms
• More severe evidence of dehydration (↑hematocrit, ↑urea)
• Younger age (<5 years)
• New-onset diabetes
• Sick appearance

RECOGNIZE CEREBRAL INJURY:

• GCS ≤13, severe/progressive headache, vomiting, focal neurological signs, incontinence
• Irritability/inconsolability in pre-verbal children
• Cushing’s triad (↑BP, ↓HR, abnormal breathing)

Contact Pediatric Referral Centre

• ALL pediatric DKA patients should receive NS or RL 20 mL/kg (MAX 1 L) IV bolus over 20 minutes.⁵ In the rare circumstance that the patient is hypotensive, give as rapid push over 5-10 minutes. Reassess perfusion.
• Repeat IV bolus in patients with ongoing hypoperfusion (capillary refill time >3 sec centrally, cool extremities) or hypotension. Reassess perfusion after each bolus. Discuss further fluid management with Pediatric Referral Centre.
• Delay start of IV infusion of insulin (0.1 units/kg/hour) until 1 hour after IV fluid is started.
• Calculate ongoing IV fluid rates using Rehydration Table below, which replaces a 10% fluid deficit and maintenance requirements over 36 hours. Use NS or RL with added KCl as per TREKK’s Pediatric DKA Algorithm.

• Add 5% dextrose to IV fluid once blood glucose is less than 17 mmol/L or if blood glucose is decreasing by more than 5 mmol/L/hr after insulin infusion is started. Increase to 10% dextrose as needed to keep blood glucose >10 mmol/L.
• Monitor blood glucose and fluid balance Q1H. Monitor venous blood gas, electrolytes, urea, and creatinine Q2H.

TREAT SUSPECTED CEREBRAL INJURY:

• Manage ABCs. Monitor BP and perfusion closely to avoid hypotension and prevent further cerebral injury.
• Elevate the head of the bed to 30 degrees; keep head in midline.
• After initial fluid resuscitation, run ongoing IV fluids at 75% of rate outlined in Rehydration Table above.⁶
• Administer 3% NaCl 5 mL/kg (MAX 250 mL) IV over 10 min OR mannitol 0.5-1 g/kg (MAX 100 g) IV over 15 min.
• May repeat hyperosmolar agent dose x 1 after 30 min if no improvement or use alternate agent.
• Head CT is not required prior to treatment or transport.

• Discuss the need for admission, transfer, or intensive care with Pediatric Diabetes Specialist and/or Pediatric Referral Centre.
• A diagnosis of Type 1 or 2 diabetes is life-changing and must be communicated sensitively and with appropriate supports in place. Key messaging should emphasize that recent advancements in diabetes care have led to much improved health and quality of life; this diagnosis should not limit the future goals and dreams of the child/youth. Receiving a diagnosis of diabetes may be devastating for young people, especially since they may know of a friend or relative with severe complications from this disease. Approach the conversation with care.

Thank you to the following content experts who led the development of the Diabetic Ketoacidosis (DKA) Bottom Line Recommendations:

Sarah Reid, MD, Pediatric Emergency Physician, Division of Emergency Medicine, Children’s Hospital of Eastern Ontario  (CHEO), Associate Professor of Pediatrics and Emergency Medicine, University of Ottawa

Karen Gripp, MD, Medical Director, HSC Winnipeg Children’s Hospital, Emergency Department; Section Head, Pediatric  Emergency Medicine, Associate Professor, Department of Pediatrics and Child Health, University of Manitoba

Thank you to the TREKK Editorial Committee and Editor Sarah Reid, who provided editorial support and expertise in the development of this resource.

Thank you as well to the following people who coordinated and oversaw the development process:

Chelsea Bowkett, TREKK Project Coordinator, University of Manitoba

Megan Bale-Nick, RD, MPH, TREKK Project Coordinator, University of Manitoba

To see our resource development process please visit our website here.

1. Edge JA, Hawkins MM, Winter DL, Dunger DB. The risk and outcome of cerebral oedema developing during diabetic ketoacidosis. Arch Dis Child 2001;85:16-22.
2. Glaser NS et al. Frequency of sub-clinical cerebral edema in children with diabetic ketoacidosis. Pediatr Diabetes 2006;7:75-80.
3. Ghetti S et al. Cognitive Function Following Diabetic Ketoacidosis in Children With New-Onset or Previously Diagnosed Type 1 Diabetes. Diabetes Care 2020;43:2768-75.
4. Kuppermann et al. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. New England Journal of Medicine 2018;378(24);2275-2287.
5. Glaser N, Fritsch M, Priyambada L, Rewers A, Cherubini V, Estrada S, Wolfsdorf JI, Codner E. ISPAD clinical practice consensus guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes. 2022;23(7):835-856.
6. Gripp K, Trottier ED, Thakore S, Sniderman L, Lawrence S; Canadian Paediatric Society, Acute Care Committee. Current recommendations for management of paediatric diabetic ketoacidosis. Dec 5 2022.

For a complete list of the evidence that informed the creation of the Diabetic Ketoacidosis Bottom Line Recommendations see the Evidence Repository here.

The purpose of this document is to provide healthcare professionals with key facts and recommendations for the diagnosis and treatment of community acquired pneumonia in children in the emergency department. The TREKK Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. THIS DOCUMENT IS SUBJECT TO FULL DISCLAIMER HERE: trekk.ca/terms-of-use