II. Management: Phase 1 - Fluids in Children (Emergent)
- Stabilize shock and Coma states first!
- Children with DKA present with at least 5 to 10% Dehydration
- Correct Volume Deficit
- Initial
- Give 10-20 cc/kg NS bolus over first 45 minutes
- Both 10 and 20 cc/kg bolus are safe with similar outcomes
- Pruitt (2019) Am J Emerg Med 37(12): 2239-41 [PubMed]
- Kuppermann (2018) N Engl J Med 378(24):2275-87 +PMID: 29897851 [PubMed]
- Repeat fluid bolus until shock corrected
- Give 10-20 cc/kg NS bolus over first 45 minutes
- Next
- Fluid deficit replacement distributed evenly over 48 hour period
- Start with NS and may continue with NS (or transition to 1/2 NS over the subsequent 8-10 hours)
- Normal Saline (NS) is often continued as maintenance fluid to prevent Hyponatremia with 1/2NS
- Rate: 5 ml/kg/hour (1.5 times maintenance)
- Use fluids without dextrose (NS or 1/2NS) until Serum Glucose <250 mg/dl, then use D5 NS or D51/2NS
- In children, Dextrose may be added to fluid starting at Serum Glucose <300 mg/dl
- Initial
- Precautions
- Follow Intake and output closely
- Do not drop Serum Osmolality (calculated) >3 mOsms/hour
- See Diabetic Ketoacidosis Related Cerebral Edema
- Suspected cerebral edema requires emergent management
- Speed of IV hydration as a cerebral edema cause is controversial (debunked in at least one study)
- Slow replacement if Fluid Overload risk (and consider close hemodynamic monitoring)
III. Management: Phase 2 - Acidosis, Electrolytes in children
-
Potassium Replacement
- Precautions
- Hypokalemia must be corrected prior to Insulin
- Hold Insulin until Potassium >2.5 meq/L in children
- Prerequisites
- Electrocardiogram without signs of Hyperkalemia
- Adequate Urine Output
- Administration: Children
- Serum Potassium <2.5 meq/L
- Do not administer Insulin until Potassium >2.5 meq/L
- KCl 1 meq/kg (to 40 meq) IV over 1 hour, recheck
- This is maximum IV Potassium rate!
- Requires cardiac monitoring
- Requires hourly recheck of Serum Potassium
- Serum Potassium 2.5 to 3.5 meq/L
- Give 40-60 meq/L in IV solution
- Recheck Serum Potassium hourly
- Continue replacement until Potassium >3.5 meq/L
- Serum Potassium 3.5 to 5.0 meq/L
- Add 30-40 meq Potassium per liter to IV fluids
- Serum Potassium >5.0 meq/L
- Do not administer any IV Potassium
- Monitor every 1 hour until <5.0 meq/L, then every 2-3 hours
- Serum Potassium <2.5 meq/L
- Precautions
-
Phosphate Replacement
- Indications
- Serum Phosphorus < 0.5-1.0 mg/dl (Severe Depletion)
- Controversial - May not be required
- Consider if cardiopulmonary adverse affects
- Contraindications
- Administration
- Indications
-
Magnesium Replacement
- Indications
- Symptomatic Hypomagnesemia (Magnesium <1 meq/L)
- Administration
- MgSO4 50%: 0.2 ml/kg/day IM divide in 3 doses
- Indications
-
Sodium Bicarbonate Replacement
- Indications
- Consider for ABG or VBG pH < 7.0 after initial hour of hydration
- However, generally avoided as pH rapidly corrects with IV fluids and Insulin
- Other contributing factors
- Shock or Coma
- Severe Hyperkalemia
- Consider for ABG or VBG pH < 7.0 after initial hour of hydration
- Administration
- See Sodium Bicarbonate in Severe Metabolic Acidosis
- Add 2 mEq/kg NaCl to NS for a final solution with no more than 155 mEq/L Sodium
- Administer solution over 1 hour
- Indications
IV. Management: Phase 3 - Glucose control in children
- Initial Insulin Dosing
- Intravenous protocol
- IV Regular Insulin drip starting at 0.1 unit/kg/hour (range 0.05 to 0.1 units/kg/h)
- Subcutaneous protocol (if IV not available)
- Bolus: Regular Insulin 0.3 units/kg SC
- Maintenance
- Per 1 Hour: 0.1 units/kg or
- Per 2 Hours: 0.15 to 0.20 units/kg
- Alternative SQ Insulin Protocol for Mild to Moderate DKA (pH >7.2)
- See Alternative Glucose Control Protocol in Children below
- Intravenous protocol
- Maintenance
- Continue Insulin Infusion until acidosis resolves
- Targets (when to start tapering)
- Anion Gap normalizes (e.g. 15 or less)
- Correct Anion Gap for albumin
- Serum Albumin will be artificially high on presentation due to Dehydration, hemoconcentration
- Anion Gap increases up to 3 mmol for each gram increase in Serum Albumin
- Beta hydroxybutyrate normalization (e.g. <1 mmol/L)
- Serum Glucose <200 mg/dl
- pH>7.3 and serum bicarbonate >18 mEq/L
- May be unreliable as Normal Saline is acidotic
- pH may remain suppressed due to Normal Saline (does not occur with LR)
- Anion Gap normalizes (e.g. 15 or less)
- Titration
- Targets
- Metabolic Acidosis improving within 6 to 8 hours
- Options for inadequate Serum Glucose change
- Option 1: If inadequate drop, then increase infusion by 0.1 unit/hour
- Option 2: Continue same Insulin rate while Metabolic Acidosis and Anion Gap are improving
- Targets
- When pH>7.3 and serum bicarbonate >15 mEq/L
- Decrease Insulin Infusion to 0.05 units/kg/hour
- Continue Insulin Infusion until SC Insulin started (with 1-2 hour overlap)
- Keep Serum Glucose at 150 to 200 mg/dl
- Consided early Insulin Glargine initiation while still on Insulin Infusion
- Associated with faster DKA resolution
- Resume home dose or use 0.2 units/kg Insulin Glargine
- Welter (2023) J Pediatr Pharmacol Ther 28(2):149-55 +PMID: 37139251 [PubMed]
-
Glucose and electolyte monitoring
- Check bedside Glucose every 30 min to 1 hour until stable
- Add dextrose to replacement fluids when Serum Glucose <250 mg/dl (see Fluids above)
- Recheck basic metabolic panel every 2-4 hours until stable (see labs below)
- Initiate subcutaneous Insulin Dosing
- Known diabetic
- Restart prior program and readjust Insulin
- New patient: Determine Insulin requirements
- Regular 0.1 to 0.25 units per kg Regular Insulin every 6-8 hours or
- Divide 0.5 to 1 unit/kg/day into twice daily regimen of short and long acting Insulin
- Known diabetic
- Initiate subcutaneous Insulin Dosing (overlapping by 30-60 min with Insulin Infusion as above)
- Known diabetic
- Restart prior program if previously well controlled and readjust Insulin
- New patient or poorly controlled Diabetes: Determine Insulin requirements
- Total SQ Insulin: 0.7 to 0.8 units/kg/day prepubertal (or 1 to 1.2 units/kg/day pubertal teens)
- Split total daily dose into basal and Bolus Insulin
- Basal insulin (Insulin Glargine): 50% of total Insulin
- Bolus Insulin (prandial Insulin): 50% of total Insulin divided into 3 daily premeal doses
- Known diabetic
V. Management: Phase 3b - Alternative SQ Insulin Protocol (Emergency Department)
- Alternative SQ Insulin Protocol (to Phase 3a above) for Mild to Moderate DKA (pH >7.2)
- Indications
- Mild to Moderate DKA (pH >7.2) AND
- Established diabetic patient with good follow-up
- Able to tolerate oral intake
- Approach
- May be initiated in Emergency Department
- Involve the patient's endocrinologist
- Allow the patient to eat
- Insulin
- Give the patient's typical Basal insulin dose (e.g. night time Lantus or Insulin Glargine)
- Give sliding scale Insulin coverage (e.g. units per Carbohydrate plus units per 50 over 150)
- Monitoring
- Perform hourly bedside Glucose
- Repeat pH and basic chemistry panel at 4 hours
- Disposition
- Admit patients with persistent Metabolic Acidosis with Anion Gap, or other complications
- Indications to consider disposition home from emergency department after 4 hours
- pH has normalized or near normalized (>7.25 or 7.3)
- Normal Anion Gap
- References
- Claudius, Behar and Rivera in Herbert (2021) EM:Rap 21(7): 2-4
- Razavi (2018) Endocrine 61(2):267-74 +PMID: 29797212 [PubMed]
VI. Management: Respiratory Failure
- Similar to approach for adult DKA Respiratory Failure
- Indications for Intubation in DKA
- Diabetic Ketoacidosis Related Cerebral Edema
- Obtunded Mental Status
- Avoid Intubation if possible
- Peri-intubation apnea is poorly tolerated by the patient with severe Metabolic Acidosis (Cardiac Arrest risk)
- High Respiratory Rate must be matched to allow facilitate acidosis correction (otherwise Metabolic Acidosis will worsen)
- If intubation is unavoidable
- Record Respiratory Rate prior to intubation
- RSI with Rocuronium (avoid Succinylcholine due to Hyperkalemia)
- Use Intubation Preoxygenation
- Leave patient on Bipap, Ventilator SIMV or Bag Valve Mask until time to insert Laryngoscope
- High flow nasal canula could be left in place throughout Endotracheal Intubation
- Optimize first pass success by the most experienced operator
- Set Ventilator rate to preintubation Respiratory Rate (typically 30-40 breaths/min in severe DKA)
- Post-intubation precautions: Breath Stacking (Auto-PEEP)
- Breath Stacking (Auto-PEEP) occurs with high Ventilator rates
- Monitor repeat VBG or ABG
- Check plateau pressure at time of inspiratory pause
- Plateau pressure >30 mmHg should prompt disconnecting vent to allow for a full expiration
- Decrease Respiratory Rate if Breath Stacking occurs
VII. Monitoring: Labs and Exam every 2-4 hours until stable
- Vital Signs and neurologic status
- Medical provider exam every 4 hours in age <2 years
- Serum Electrolytes (including Serum Potassium and Serum Sodium)
- Serum Creatinine
- Venous Blood Gas (VBG)
- Serum Glucose (checked every 30 min to hour as above)
VIII. Management: Disposition
-
Intensive Care Unit (ICU) Indications
- Severe DKA (e.g. pH <7.1)
- Altered Mental Status
- Abnormal Electrolytes
- Transfer to pediatric tertiary care for moderate to severe DKA
- Use Critical Care Transport when available
IX. References
- Fahlsing and Ponce (2024) Crit Dec Emerg Med 38(3): 18-9
- Brink (1999) Diabetes Nutr Metab 12:122-35 [PubMed]
- Kitabchi (2001) Diabetes Care 24:131-53 [PubMed]
- Kitabchi (2004) Diabetes Care 27(suppl 1): S94-102 [PubMed]
- Trachtenbarg (2005) Am Fam Physician 71: 1705-22 [PubMed]
- Tzimenatos (2021) Ann Emerg Med 78(3): 340-5 [PubMed]
- Veauthier (2024) Am Fam Physician 110(5): 476-86 [PubMed]