Diabetic Ketoacidosis Management in Children

Aka: Diabetic Ketoacidosis Management in Children, Pediatric DKA Treatment

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II. Management: Phase 1 - Fluids in Children (Emergent)

  1. Stabilize shock and Coma states first!
  2. Children with DKA present with at least 5 to 10% Dehydration
  3. Correct Volume Deficit
    1. Initial
      1. Give 10-20 cc/kg NS bolus over first 20-30 min (previously over 45 min)
        1. Both 10 and 20 cc/kg bolus are safe with similar outcomes
        2. Pruitt (2019) Am J Emerg Med 37(12): 2239-41 [PubMed]
        3. Kuppermann (2018) N Engl J Med 378(24):2275-87 +PMID: 29897851 [PubMed]
      2. Repeat fluid bolus until shock corrected
    2. Next
      1. Fluid deficit replacement distributed evenly over 48 hour period
      2. Start with NS and may continue with NS (or transition to 1/2 NS over the subsequent 8-10 hours)
        1. Normal Saline (NS) is often continued as maintenance fluid to prevent Hyponatremia with 1/2NS
      3. Rate: 5 ml/kg/hour (1.5 times maintenance)
      4. Use fluids without dextrose (NS or 1/2NS) until Serum Glucose <250 mg/dl, then use D5 NS or D51/2NS
        1. In children, Dextrose may be added to fluid starting at Serum Glucose <300 mg/dl
  4. Precautions
    1. Follow Intake and output closely
    2. Do not drop Serum Osmolality (calculated) >3 mOsms/hour
      1. See Diabetic Ketoacidosis Related Cerebral Edema
      2. Suspected cerebral edema requires emergent management
      3. Speed of IV hydration as a cerebral edema cause is controversial (debunked in at least one study)
    3. Slow replacement if Fluid Overload risk (and consider close hemodynamic monitoring)
      1. Congestive Heart Failure
      2. Chronic Renal Insufficiency

III. Management: Phase 2 - Acidosis, Electrolytes in children

  1. Potassium Replacement
    1. Precautions
      1. Hypokalemia must be corrected prior to Insulin
      2. Hold Insulin until Potassium >2.5 meq/L in children
    2. Prerequisites
      1. Electrocardiogram without signs of Hyperkalemia
      2. Adequate Urine Output
    3. Administration: Children
      1. Serum Potassium <2.5 meq/L
        1. Do not administer Insulin until Potassium >2.5 meq/L
        2. KCl 1 meq/kg (to 40 meq) IV over 1 hour, recheck
          1. This is maximum IV Potassium rate!
          2. Requires cardiac monitoring
          3. Requires hourly recheck of Serum Potassium
      2. Serum Potassium 2.5 to 3.5 meq/L
        1. Give 40-60 meq/L in IV solution
        2. Recheck Serum Potassium hourly
        3. Continue replacement until Potassium >3.5 meq/L
      3. Serum Potassium 3.5 to 5.0 meq/L
        1. Add 30-40 meq Potassium per liter to IV fluids
      4. Serum Potassium >5.0 meq/L
        1. Do not administer any IV Potassium
        2. Monitor every 1 hour until <5.0 meq/L, then every 2-3 hours
  2. Phosphate Replacement
    1. Indications
      1. Serum Phosphorus < 0.5-1.0 mg/dl (Severe Depletion)
      2. Controversial - May not be required
      3. Consider if cardiopulmonary adverse affects
    2. Contraindications
      1. Renal Insufficiency
    3. Administration
      1. Determine Potassium Replacement as above
      2. Replace part of Potassium with Potassium phosphate
        1. Potassium Phosphate: Replace one third Potassium
        2. Potassium Chloride: Replace two thirds Potassium
  3. Magnesium Replacement
    1. Indications
      1. Symptomatic Hypomagnesemia (Magnesium <1 meq/L)
    2. Administration
      1. MgSO4 50%: 0.2 ml/kg/day IM divide in 3 doses
  4. Sodium Bicarbonate Replacement
    1. Indications
      1. Consider for ABG or VBG pH < 7.0 after initial hour of hydration
        1. However, generally avoided as pH rapidly corrects with IV fluids and Insulin
      2. Other contributing factors
        1. Shock or Coma
        2. Severe Hyperkalemia
    2. Administration
      1. See Sodium Bicarbonate in Severe Metabolic Acidosis
      2. Add 2 mEq/kg NaCl to NS for a final solution with no more than 155 mEq/L Sodium
      3. Administer solution over 1 hour

IV. Management: Phase 3 - Glucose control in children

  1. Initial Insulin Dosing
    1. Intravenous protocol
      1. IV Regular Insulin drip starting at 0.1 unit/kg/hour (range 0.05 to 0.1 units/kg/h)
    2. Subcutaneous protocol (if IV not available)
      1. Bolus: Regular Insulin 0.3 units/kg SC
      2. Maintenance
        1. Per 1 Hour: 0.1 units/kg or
        2. Per 2 Hours: 0.15 to 0.20 units/kg
    3. Alternative SQ Insulin Protocol for Mild to Moderate DKA (pH >7.2)
      1. See Alternative Glucose Control Protocol in Children below
  2. Maintenance
    1. Continue Insulin Infusion until acidosis resolves
    2. Targets (when to start tapering)
      1. Anion Gap normalizes (e.g. 15 or less)
        1. Correct Anion Gap for albumin
        2. Serum Albumin will be artificially high on presentation due to Dehydration, hemoconcentration
        3. Anion Gap increases up to 3 mmol for each gram increase in Serum Albumin
      2. Beta hydroxybutyrate normalization (e.g. <1 mmol/L)
      3. Serum Glucose <200 mg/dl
      4. pH>7.3 and serum bicarbonate >18 mEq/L
        1. May be unreliable as Normal Saline is acidotic
        2. pH may remain suppressed due to Normal Saline (does not occur with LR)
    3. Titration
      1. Targets
        1. Metabolic Acidosis improving within 6 to 8 hours
      2. Options for inadequate Serum Glucose change
        1. Option 1: If inadequate drop, then increase infusion by 0.1 unit/hour
        2. Option 2: Continue same Insulin rate while Metabolic Acidosis and Anion Gap are improving
  3. When pH>7.3 and serum bicarbonate >15 mEq/L
    1. Decrease Insulin Infusion to 0.05 units/kg/hour
    2. Continue Insulin Infusion until SC Insulin started (with 1-2 hour overlap)
    3. Keep Serum Glucose at 150 to 200 mg/dl
    4. Consided early Insulin Glargine initiation while still on Insulin Infusion
      1. Associated with faster DKA resolution
      2. Resume home dose or use 0.2 units/kg Insulin Glargine
      3. Welter (2023) J Pediatr Pharmacol Ther 28(2):149-55 +PMID: 37139251 [PubMed]
  4. Glucose and electolyte monitoring
    1. Check bedside Glucose every 30 min to 1 hour until stable
    2. Add dextrose to replacement fluids when Serum Glucose <250 mg/dl (see Fluids above)
    3. Recheck basic metabolic panel every 2-4 hours until stable (see labs below)
  5. Initiate subcutaneous Insulin Dosing
    1. Known diabetic
      1. Restart prior program and readjust Insulin
    2. New patient: Determine Insulin requirements
      1. Regular 0.1 to 0.25 units per kg Regular Insulin every 6-8 hours or
      2. Divide 0.5 to 1 unit/kg/day into twice daily regimen of short and long acting Insulin
        1. AM (66%): Give 1/3 short acting and 2/3 intermediate to long actng Insulin
        2. PM (33%): Give 1/2 short acting and 1/2 intermediate to long actng Insulin
  6. Initiate subcutaneous Insulin Dosing (overlapping by 30-60 min with Insulin Infusion as above)
    1. Known diabetic
      1. Restart prior program if previously well controlled and readjust Insulin
    2. New patient or poorly controlled Diabetes: Determine Insulin requirements
      1. Total SQ Insulin: 0.7 to 0.8 units/kg/day prepubertal (or 1 to 1.2 units/kg/day pubertal teens)
      2. Split total daily dose into basal and Bolus Insulin
        1. Basal insulin (Insulin Glargine): 50% of total Insulin
        2. Bolus Insulin (prandial Insulin): 50% of total Insulin divided into 3 daily premeal doses

V. Management: Phase 3b - Alternative SQ Insulin Protocol (Emergency Department)

  1. Alternative SQ Insulin Protocol (to Phase 3a above) for Mild to Moderate DKA (pH >7.2)
  2. Indications
    1. Mild to Moderate DKA (pH >7.2) AND
    2. Established diabetic patient with good follow-up
    3. Able to tolerate oral intake
  3. Approach
    1. May be initiated in Emergency Department
    2. Involve the patient's endocrinologist
    3. Allow the patient to eat
    4. Insulin
      1. Give the patient's typical Basal insulin dose (e.g. night time Lantus or Insulin Glargine)
      2. Give sliding scale Insulin coverage (e.g. units per Carbohydrate plus units per 50 over 150)
    5. Monitoring
      1. Perform hourly bedside Glucose
      2. Repeat pH and basic chemistry panel at 4 hours
    6. Disposition
      1. Admit patients with persistent Metabolic Acidosis with Anion Gap, or other complications
      2. Indications to consider disposition home from emergency department after 4 hours
        1. pH has normalized or near normalized (>7.25 or 7.3)
        2. Normal Anion Gap
    7. References
      1. Claudius, Behar and Rivera in Herbert (2021) EM:Rap 21(7): 2-4
      2. Razavi (2018) Endocrine 61(2):267-74 +PMID: 29797212 [PubMed]

VI. Management: Respiratory Failure

  1. Similar to approach for adult DKA Respiratory Failure
  2. Indications for Intubation in DKA
    1. Diabetic Ketoacidosis Related Cerebral Edema
    2. Obtunded Mental Status
  3. Avoid Intubation if possible
    1. Peri-intubation apnea is poorly tolerated by the patient with severe Metabolic Acidosis (Cardiac Arrest risk)
    2. High Respiratory Rate must be matched to allow facilitate acidosis correction (otherwise Metabolic Acidosis will worsen)
  4. If intubation is unavoidable
    1. Record Respiratory Rate prior to intubation
    2. RSI with Rocuronium (avoid Succinylcholine due to Hyperkalemia)
    3. Use Intubation Preoxygenation
    4. Leave patient on Bipap, Ventilator SIMV or Bag Valve Mask until time to insert Laryngoscope
      1. High flow nasal canula could be left in place throughout Endotracheal Intubation
    5. Optimize first pass success by the most experienced operator
    6. Set Ventilator rate to preintubation Respiratory Rate (typically 30-40 breaths/min in severe DKA)
  5. Post-intubation precautions: Breath Stacking (Auto-PEEP)
    1. Breath Stacking (Auto-PEEP) occurs with high Ventilator rates
    2. Monitor repeat VBG or ABG
    3. Check plateau pressure at time of inspiratory pause
      1. Plateau pressure >30 mmHg should prompt disconnecting vent to allow for a full expiration
      2. Decrease Respiratory Rate if Breath Stacking occurs

VII. Monitoring: Labs and Exam every 2-4 hours until stable

  1. Vital Signs and neurologic status
  2. Medical provider exam every 4 hours in age <2 years
  3. Serum Electrolytes (including Serum Potassium and Serum Sodium)
  4. Serum Creatinine
  5. Venous Blood Gas (VBG)
  6. Serum Glucose (checked every 30 min to hour as above)

VIII. Management: Disposition

  1. Intensive Care Unit (ICU) Indications
    1. Severe DKA (e.g. pH <7.1)
    2. Altered Mental Status
    3. Abnormal Electrolytes
  2. Transfer to pediatric tertiary care for moderate to severe DKA
    1. Use Critical Care Transport when available

IX. References

  1. Fahlsing and Ponce (2024) Crit Dec Emerg Med 38(3): 18-9
  2. Brink (1999) Diabetes Nutr Metab 12:122-35 [PubMed]
  3. Glaser (2022) Pediatr Diabetes 23(7):835-6 +PMID: 36250645 [PubMed]
  4. Kitabchi (2001) Diabetes Care 24:131-53 [PubMed]
  5. Kitabchi (2004) Diabetes Care 27(suppl 1): S94-102 [PubMed]
  6. Trachtenbarg (2005) Am Fam Physician 71: 1705-22 [PubMed]
  7. Tzimenatos (2021) Ann Emerg Med 78(3): 340-5 [PubMed]
  8. Veauthier (2024) Am Fam Physician 110(5): 476-86 [PubMed]

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