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Pediatric Diabetic Ketoacidosis Emergency Department Care Treatment & Management

  • Author: Grace M Young, MD; Chief Editor: Stephen Kemp, MD, PhD  more...
Updated: Dec 16, 2015

Prehospital Care

Provide oxygen and advanced airway management in patients with diabetic ketoacidosis (DKA), if needed.[7]

Monitor the patient.

Provide isotonic intravenous fluids (eg, isotonic sodium chloride solution or lactated Ringer solution).

Perform fingerstick glucose testing.

Consider empiric naloxone if altered mental status is present.


Emergency Department Care

Multiple goals are noted for the acute treatment of diabetic ketoacidosis (DKA), including volume resuscitation, identification and treatment of the precipitant event, insulin therapy, hourly monitoring of serum markers of diabetic ketoacidosis, and prevention of complications from rapid decreases in serum osmolarity. Each aspect of diabetic ketoacidosis management must be closely monitored.[8, 9, 10]

Alter fluid, glucose, and insulin administration in response to the dynamic and often volatile metabolic changes that occur during treatment.[11] A flow sheet is invaluable to monitor and document the progression of diabetic ketoacidosis management and is shown in the image below.

Sample diabetic ketoacidosis flow sheet. Sample diabetic ketoacidosis flow sheet.

Concurrent with management of diabetic ketoacidosis are basics of emergency resuscitation (eg, management of urgent airway, breathing, and circulation).

In addition to these basics, patients with diabetic ketoacidosis should remain on a diet of nothing by mouth (NPO), receive supplemental oxygen and, if bacterial infection is suspected, empiric antibiotic therapy.

The goal of the first hour of treatment is volume resuscitation and confirmation of diabetic ketoacidosis by laboratory studies, as follows:

  • Fluids - Isotonic sodium chloride solution bolus, 20 mL/kg intravenously over an hour or less
  • Glucose - None, unless serum glucose level falls to 250-300 mg/dL during rehydration

The goals of the second and succeeding hours are slow correction of hyperglycemia (with glucose level falling at a rate < 100 mg/dL/h), metabolic acidosis, and ketosis, in addition to continued volume replenishment.


These goals must be met in a manner that prevents too rapid a decrease in serum osmolarity.

This usually requires several hours and meticulous attention to the patient's response to therapy.

Careful observation is warranted to ensure that the patient does not become hypoglycemic.

Hypoglycemia may occur abruptly as insulin resistance resolves.

To this end, maintain glucose levels above 150-250 mg/dL.

During this period, admit the patient to an inpatient setting.


Give isotonic sodium chloride solution or 0.45 isotonic sodium chloride solution (0.45% NaCl) with supplemental potassium at twice maintenance rate.

Add potassium as KCl, potassium phosphate, or potassium acetate.

If serum potassium level is in the low life-threatening range, consider replenishing potassium orally (or by nasogastric tube) in a liquid (not tablet) formulation. This corrects hypokalemia much more rapidly than intravenous replenishment, the rate of which must be reduced because of cardiac considerations.

If serum potassium level is less than 3.5, add 40 mEq/L to intravenous fluids.

If serum potassium level is 3.5-5, add 30 mEq/L to intravenous fluids.

If serum potassium level is 5-5.5, add 20 mEq/L to intravenous fluids.

If serum potassium level is greater than 5.5, do not add additional potassium to intravenous fluids.

If serum potassium level is not immediately available, perform an ECG to search for electrocardiographic signs of hyperkalemia.


Do not give insulin until severe hypokalemia is corrected.

Then give 0.1 U/kg intravenous bolus; follow with insulin 0.1 U/kg/h intravenously by constant infusion. Prime all intravenous tubing before the bolus because insulin binds to intravenous tubing.

As a result of the potential for hypoglycemia, forego the insulin bolus if the serum glucose level is less than 500 mg/dL or if the child is known to be hypersensitive to exogenous insulin.

To prepare the insulin drip, add units of regular insulin equal to the patient's kilogram weight to 100 mL saline. Saturate the intravenous tubing with 20 mL of the insulin solution, and set the infusion rate equal to 10 mL/h. This provides 0.1 U/kg/h.

Use regular human insulin, unless the patient uses bovine insulin.


Add 5% dextrose (D5 or D10) to intravenous fluids, if the child remains in ketoacidosis and serum glucose level approaches 250-300 mg/dL.

Do not discontinue the insulin drip, as the child remains in ketoacidosis for some time and insulin is critical in eliminating ketoacidosis.

Maintain the serum glucose concentration at 150-250 mg/dL during insulin infusion.

Titrate the insulin and glucose infusions, noting that 1 unit of regular insulin metabolizes 3 g of glucose.

The final goal is to obtain a serum glucose concentration within the reference range (serum glucose level, 100-150 mg/dL), to obtain neutral blood pH (pH =7.4; serum bicarbonate = 15-18 mEq/dL), and to eliminate serum ketones. This phase includes the transition from parenteral to subcutaneous insulin and from a fasting state to oral fluids. It usually occurs in the inpatient setting (see Further Inpatient Care) under the direction of a pediatric endocrinologist.


Give 0.45% sodium chloride solution with dextrose and potassium up to twice maintenance rate.

Consider oral fluids if nausea is absent.


Set the intravenous infusion at 0.05-0.10 U/kg/h.


Consider 5-10% dextrose in intravenous fluids to maintain serum glucose level at least 150 mg/dL.



A pediatric endocrinologist may be useful in complicated cases.

Transfer to a pediatric intensive care unit is prudent for the patient with persistent altered mental status, resistant acidosis, and hemodynamic instability, and for the first-time newly diagnosed patient.



Cerebral edema

Cerebral edema occurs in 0.7-1% of children with diabetic ketoacidosis.

Causes are multifactorial but may include too-rapid infusion of fluids and electrolytes, overhydration, and overly aggressive correction of acidosis or hyperglycemia.

Treatment includes intubation, hyperventilation, and mannitol 0.25-1 g/kg intravenously.


Causes include increased sensitivity to exogenous insulin and insufficient serum glucose for insulin to metabolize.

Treatment includes adding 5-10% dextrose to intravenous fluids when serum glucose level is 250-300 mg/dL.


Serum potassium begins to reflect actual total body potassium depletion as volume depletion and acidosis resolve.

Add potassium to intravenous fluids (see Emergency Department Care) when urine output is present and results of serum potassium level are available.

Cardiac dysrhythmia

Causes include hyperkalemia, hypokalemia, and hypocalcemia.

Treatment involves correcting the specific cause.

Pulmonary edema

Causes include low plasma oncotic pressure and increased pulmonary capillary permeability.

Treatment includes oxygen and diuresis.



If the patient is known to have diabetes, maintain compliance with an insulin therapy regimen and close contact with the treating physician. This is especially important in the presence of nausea, vomiting, and abdominal pain.


Long-Term Monitoring

Admit children with diabetic ketoacidosis (DKA) for further evaluation, observation, management, diabetes education, and assessment of compliance by responsible caretakers.

Assess the need for social service intervention.

Contributor Information and Disclosures

Grace M Young, MD Associate Professor, Department of Pediatrics, University of Maryland Medical Center

Grace M Young, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center; Chairman, Pediatric Institutional Review Board, Mercy St Vincent Medical Center, Toledo, Ohio

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Stephen Kemp, MD, PhD Former Professor, Department of Pediatrics, Section of Pediatric Endocrinology, University of Arkansas for Medical Sciences College of Medicine, Arkansas Children's Hospital

Stephen Kemp, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Association of Clinical Endocrinologists, American Pediatric Society, Endocrine Society, Phi Beta Kappa, Southern Medical Association, Southern Society for Pediatric Research

Disclosure: Nothing to disclose.

Additional Contributors

James Li, MD Former Assistant Professor, Division of Emergency Medicine, Harvard Medical School; Board of Directors, Remote Medicine

Disclosure: Nothing to disclose.

  1. Kisiel M, Marsons L. Recognizing and responding to hyperglycaemic emergencies. Br J Nurs. 2009 Oct 8-21. 18(18):1094-8. [Medline].

  2. Kurien M, Mollazadegan K, Sanders DS, Ludvigsson JF. A nationwide population-based study on the risk of coma, ketoacidosis and hypoglycemia in patients with celiac disease and type 1 diabetes. Acta Diabetol. 2015 Sep 24. [Medline].

  3. Hsia DS, Tarai SG, Alimi A, Coss-Bu JA, Haymond MW. Fluid management in pediatric patients with DKA and rates of suspected clinical cerebral edema. Pediatr Diabetes. 2015 Aug. 16 (5):338-44. [Medline].

  4. Wolfsdorf J, Glaser N, Sperling MA; American Diabetes Association. Diabetic ketoacidosis in infants, children, and adolescents: A consensus statement from the American Diabetes Association. Diabetes Care. 2006 May. 29(5):1150-9. [Medline].

  5. Tiwari LK, Muralindharan J, Singhi S. Risk factors for cerebral edema in diabetic ketoacidosis in a developing country: Role of fluid refractory shock*. Pediatr Crit Care Med. 2012 Mar. 13(2):e91-6. [Medline].

  6. Bui H, To T, Stein R, Fung K, Daneman D. Is Diabetic Ketoacidosis at Disease Onset a Result of Missed Diagnosis?. J Pediatr. 2009 Dec 2. [Medline].

  7. [Guideline] Kitabchi AE, Umpierrez GE, Murphy MB, et al. Hyperglycemic crises in diabetes. Diabetes Care. 2004 Jan. 27 Suppl 1:S94-102. [Medline].

  8. Rosenbloom AL. The management of diabetic ketoacidosis in children. Diabetes Ther. 2010 Dec. 1(2):103-20. [Medline]. [Full Text].

  9. Clark MG, Dalabih A. Variability of DKA Management Among Pediatric Emergency Room and Critical Care Providers: A Call for More Evidence-Based and Cost-Effective Care?. J Clin Res Pediatr Endocrinol. 2014 Sep. 6 (3):190-1. [Medline].

  10. Koves IH, Leu MG, Spencer S, Popalisky JC, Drummond K, Beardsley E, et al. Improving care for pediatric diabetic ketoacidosis. Pediatrics. 2014 Sep. 134 (3):e848-56. [Medline].

  11. Kapellen T, Vogel C, Telleis D, Siekmeyer M, Kiess W. Treatment of Diabetic Ketoacidosis (DKA) with 2 Different Regimens Regarding Fluid Substitution and Insulin Dosage (0.025 vs. 0.1?units/kg/h). Exp Clin Endocrinol Diabetes. 2012 Feb 10. [Medline].

  12. Nallasamy K, Jayashree M, Singhi S, Bansal A. Low-dose vs standard-dose insulin in pediatric diabetic ketoacidosis: a randomized clinical trial. JAMA Pediatr. 2014 Nov. 168 (11):999-1005. [Medline].

  13. Ackerman A. Cerebral edema in pediatric diabetic ketoacidosis: Can six patients make a difference?. Crit Care Med. 2006 Aug. 34(8):2258-9. [Medline].

  14. Agus MS, Wolfsdorf JI. Diabetic ketoacidosis in children. Pediatr Clin North Am. 2005 Aug. 52(4):1147-63, ix. [Medline].

  15. Alawi KA, Morrison GC, Fraser DD, Al-Farsi S, Collier C, Kornecki A. Insulin infusion via an intraosseous needle in diabetic ketoacidosis. Anaesth Intensive Care. 2008 Jan. 36(1):110-2. [Medline].

  16. Bismuth E, Laffel L. Can we prevent diabetic ketoacidosis in children?. Pediatr Diabetes. 2007 Oct. 8 Suppl 6:24-33. [Medline].

  17. Bonadio W. Pediatric diabetic ketoacidosis: an outpatient perspective on evaluation and management. Pediatr Emerg Med Pract. 2013 Mar. 10(3):1-13; quiz 14. [Medline].

  18. Cardella F. Insulin therapy during diabetic ketoacidosis in children. Acta Biomed Ateneo Parmense. 2005. 76 Suppl 3:49-54. [Medline].

  19. Cody D. Infant and toddler diabetes. Arch Dis Child. 2007 Aug. 92(8):716-9. [Medline].

  20. Dunger DB, Sperling MA, Acerini CL, et al. ESPE/LWPES consensus statement on diabetic ketoacidosis in children and adolescents. Arch Dis Child. 2004 Feb. 89(2):188-94. [Medline].

  21. Dunger DB, Sperling MA, Acerini CL, et al. European Society for Paediatric Endocrinology/Lawson Wilkins Pediatric Endocrine Society consensus statement on diabetic ketoacidosis in children and adolescents. Pediatrics. 2004 Feb. 113(2):e133-40. [Medline].

  22. Edge JA, Hawkins MM, Winter DL, Dunger DB. The risk and outcome of cerebral oedema developing during diabetic ketoacidosis. Arch Dis Child. 2001 Jul. 85(1):16-22. [Medline].

  23. Fiordalisi I, Novotny WE, Holbert D, Finberg L, Harris GD. An 18-yr prospective study of pediatric diabetic ketoacidosis: an approach to minimizing the risk of brain herniation during treatment. Pediatr Diabetes. 2007 Jun. 8(3):142-9. [Medline].

  24. Friedman AL. Choosing the right fluid and electrolytes prescription in diabetic ketoacidosis. J Pediatr. 2007 May. 150(5):455-6. [Medline].

  25. Glaser N. Cerebral injury and cerebral edema in children with diabetic ketoacidosis: could cerebral ischemia and reperfusion injury be involved?. Pediatr Diabetes. 2009 Dec. 10(8):534-41. [Medline].

  26. Glaser N. New perspectives on the pathogenesis of cerebral edema complicating diabetic ketoacidosis in children. Pediatr Endocrinol Rev. 2006 Jun. 3(4):379-86. [Medline].

  27. Glaser N, Barnett P, McCaslin I, et al. Risk factors for cerebral edema in children with diabetic ketoacidosis. The Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. N Engl J Med. 2001 Jan 25. 344(4):264-9. [Medline].

  28. Glaser N, Kuppermann N. DKA-related cerebral edema and intravenous fluid therapy: potential pitfalls of uncontrolled retrospective studies. J Pediatr. 2008 Jan. 152(1):145; author reply 147-9. [Medline].

  29. Glaser N, Kuppermann N. The evaluation and management of children with diabetic ketoacidosis in the emergency department. Pediatr Emerg Care. 2004 Jul. 20(7):477-81; quiz 482-4. [Medline].

  30. Glaser NS, Ghetti S, Casper TC, Dean JM, Kuppermann N. Pediatric diabetic ketoacidosis, fluid therapy, and cerebral injury: the design of a factorial randomized controlled trial. Pediatr Diabetes. 2013 Sep. 14(6):435-46. [Medline]. [Full Text].

  31. Glaser NS, Wootton-Gorges SL, Buonocore MH, et al. Frequency of sub-clinical cerebral edema in children with diabetic ketoacidosis. Pediatr Diabetes. 2006 Apr. 7(2):75-80. [Medline].

  32. Green SM, Rothrock SG, Ho JD, et al. Failure of adjunctive bicarbonate to improve outcome in severe pediatric diabetic ketoacidosis. Ann Emerg Med. 1998 Jan. 31(1):41-8. [Medline].

  33. Hanas R, Lindgren F, Lindblad B. Diabetic ketoacidosis and cerebral oedema in Sweden--a 2-year paediatric population study. Diabet Med. 2007 Oct. 24(10):1080-5. [Medline].

  34. Hoorn EJ, Carlotti AP, Costa LA, MacMahon B, Bohn G, Zietse R, et al. Preventing a drop in effective plasma osmolality to minimize the likelihood of cerebral edema during treatment of children with diabetic ketoacidosis. J Pediatr. 2007 May. 150(5):467-73. [Medline].

  35. Lawson M. Predictors of acute complications in children with type I diabetes. J Pediatr. 2002 Nov. 141(5):739-40. [Medline].

  36. Mahmud FH, Ramsay DA, Levin SD, Singh RN, Kotylak T, Fraser DD. Coma with diffuse white matter hemorrhages in juvenile diabetic ketoacidosis. Pediatrics. 2007 Dec. 120(6):e1540-6. [Medline].

  37. Marcin JP, Glaser N, Barnett P, et al. Factors associated with adverse outcomes in children with diabetic ketoacidosis-related cerebral edema. J Pediatr. 2002 Dec. 141(6):793-7. [Medline].

  38. Munk MD. Pediatric DKA. The presentation, assessment & prehospital management of diabetic ketoacidosis in children. JEMS. 2006 Jun. 31(6):70-72, 74-80, 82; quiz 84. [Medline].

  39. Noyes KJ, Crofton P, Bath LE, Holmes A, Stark L, Oxley CD, et al. Hydroxybutyrate near-patient testing to evaluate a new end-point for intravenous insulin therapy in the treatment of diabetic ketoacidosis in children. Pediatr Diabetes. 2007 Jun. 8(3):150-6. [Medline].

  40. Olivieri L, Chasm R. Diabetic ketoacidosis in the pediatric emergency department. Emerg Med Clin North Am. 2013 Aug. 31(3):755-73. [Medline].

  41. Rewers A. Current controversies in treatment and prevention of diabetic ketoacidosis. Adv Pediatr. 2010. 57(1):247-67. [Medline].

  42. Rewers A, Chase HP, Mackenzie T, et al. Predictors of acute complications in children with type 1 diabetes. JAMA. 2002 May 15. 287(19):2511-8. [Medline].

  43. Rosenbloom AL. Treatment of diabetic ketoacidosis and the risk of cerebral edema. J Pediatr. 2008 Jan. 152(1):146-7; author reply 147-9. [Medline].

  44. Sema A, Puliyel JM. Cerebral edema in diabetic ketoacidosis with serum sodium 1J Pediatr</i>. 2008 Jan. 152(1):145-6; author reply 147-9. [Medline].

  45. Shastry RM, Bhatia V. Cerebral edema in diabetic ketoacidosis. Indian Pediatr. 2006 Aug. 43(8):701-8. [Medline].

  46. Siqueira LF. Cerebrovascular complications of diabetic ketoacidosis in children. Arq Bras Endocrinol Metabol. 2011 Jun. 55(4):288-90. [Medline].

  47. Takaya J, Ohashi R, Harada Y, Yamato F, Higashino H, Kobayashi Y, et al. Cerebral edema in a child with diabetic ketoacidosis before initial treatment. Pediatr Int. 2007 Jun. 49(3):395-6. [Medline].

  48. Vanelli M, Chiarelli F. Treatment of diabetic ketoacidosis in children and adolescents. Acta Biomed. 2003 Aug. 74(2):59-68. [Medline].

  49. Wolfsdorf J, Craig ME, Daneman D, Dunger D, Edge J, Lee WR, et al. Diabetic ketoacidosis. Pediatr Diabetes. 2007 Feb. 8(1):28-43. [Medline].

Sample diabetic ketoacidosis flow sheet.
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