Diabetic Ketoacidosis Management in Children

See Also

Management
Phase 1 - Fluids in Children (Emergent)

Stabilize shock and Coma states first!
Correct Volume Deficit
1. Initial
  1. Give 10-20 cc/kg NS bolus over first 45 minutes
    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 transition to 1/2 NS over th subsequent 8-10 hours
  3. Rate: 5 ml/kg/hour (1.5 times maintenance)
  4. Use fluids without dextrose (1/2NS) until Serum Glucose <250 mg/dl, then use D5 1/2NS
    1. Could also continue NS until Serum Glucose <200-250 mg/dl, then transition to D5 1/2 NS
Precautions
1. Do not drop Serum Osmolality (calc) >3 mOsms/hour
  1. Diabetic Ketoacidosis Related Cerebral Edema
  2. Risk of cerebral edema
2. Slow replacement if Fluid Overload risk (and consider close hemodynamic monitoring)
  1. Congestive Heart Failure
  2. Chronic Renal Insufficiency
3. Follow Intake and output closely

Management
Phase 2 - Acidosis, Electrolytes in children

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
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
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
Sodium Bicarbonate Replacement
1. Indications
  1. ABG pH < 7.0 after initial hour of hydration
  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

Management
Phase 3 - Glucose control in children

Initial Insulin Dosing
1. Intravenous protocol
  1. IV Regular Insulin drip starting at 0.1 unit/kg/hour
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
Maintenance
1. Continue Insulin Infusion until acidosis resolves
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
Glucose and electolyte monitoring
1. Check bedside Glucose every 30 min to 2 hours 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)
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

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
1. Mild to Moderate DKA (pH >7.2) AND
2. Established diabetic patient with good follow-up
3. Able to tolerate oral intake
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]

Management
Respiratory Failure

Similar to approach for adult DKA Respiratory Failure
Indications for Intubation in DKA
1. Diabetic Ketoacidosis Related Cerebral Edema
2. Obtunded Mental Status
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)
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)
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

Monitoring
Labs every 2-4 hours until stable

Serum Electrolytes
Serum Creatinine
Blood Urea Nitrogen
Serum Glucose (checked every 30 min to hour as above)

References