Pediatric Diabetic Ketoacidosis Treatment & Management

  • Author: William H Lamb, MBBS, MD, FRCP(Edin), FRCP, FRCPCH; Chief Editor: Timothy E Corden, MD   more...
 
Updated: Aug 19, 2011
 

Medical Care

As always, in patients with diabetic ketoacidosis (DKA), the first principals of resuscitation apply (ie, ABCs).[1] Outcomes are best when children are closely monitored and changing status is promptly addressed.[34, 35] Give oxygen, although this has no effect on the respiratory drive of acidosis. Diagnose by clinical history, physical signs, and elevated blood glucose.

Fluid replacement

No randomized trials of fluid replacement have been conducted, and over the years, various regimens have been proposed. Published series suggest the best outcomes have been achieved by using isotonic sodium chloride solution or half-strength sodium chloride solution for first resuscitation and replacement.[35] Slowly correcting the fluid deficit over 48 hours appears safer than rapid rehydration and, thus, forms the basis for the regimen that follows:

  • Calculate fluid deficit by weight loss or clinical assessment to a maximum 8% of body weight.
  • In a child with severe acidosis or compromised circulation, an initial resuscitation of 10-20 mL/kg of isotonic sodium chloride solution (0.9%) can be administered over 30 minutes.
  • Remember to subtract any initial resuscitation fluid boluses given from the total calculated deficit.
  • After resuscitation, slowly correct the fluid deficit over 48 hours by providing normal maintenance fluids together with the calculated deficit.
  • Administer isotonic sodium chloride solution until blood glucose levels have fallen to 250-300 mg/dL (ie, 12-15 mmol/L), at which time glucose-containing fluids should be introduced (either 5% glucose with 0.9% saline or 5% glucose with 0.45% saline). Continue maintenance with dextrose saline until the child is eating and drinking normally.
  • If cerebral edema develops, restrict fluid replacement to two thirds of normal maintenance and replace the deficit over 48 or more hours.
  • Although strict assessment of fluid balance is important, replacement of ongoing losses is not normally required.
  • The fluid maintenance rates typically advised for children are probably too generous for use in children with diabetic ketoacidosis. The following table can be used to calculate more appropriate infusion rates.

Table 2. Suggested daily maintenance fluid replacement rates. (Open Table in a new window)

WeightInfusion rate
0-12.9 kg80 mL/kg/24 h
13-19.9 kg65 mL/kg/24 h
20-34.9 kg55 mL/kg/24 h
35-59.945 mL/kg/24 h
Adult (>60 kg)35 mL/kg/24 h

Insulin replacement

Continuous, low-dose intravenous (IV) insulin infusion is generally accepted as the safest and most effective method of insulin delivery for treating diabetic ketoacidosis. Low-dose IV insulin infusion is simple, provides more physiological serum levels of insulin, allows gradual correction of hyperglycemia, and reduces the likelihood of sudden hypoglycemia and hypokalemia.

The results of a prospective national study of diabetic ketoacidosis in the United Kingdom suggest a greater risk of cerebral edema in patients who received insulin within the first hour of treatment.[8] In light of these results, starting insulin therapy an hour after fluid resuscitation has commenced is prudent, especially in the newly diagnosed child.

The correct dose of insulin to infuse in the treatment of diabetic ketoacidosis is under debate. Traditionally, 0.1 U/kg/h is given, but a lower dose of 0.05 U/kg/h is enough to prevent gluconeogenesis and results in a slower reduction of blood glucose levels. One study showed no disadvantage to using the lower infusion rate of 0.05 U/kg/h.[36] Adolescents with secondary diabetic ketoacidosis and insulin resistance may need more than 0.1 U/kg/h.

Authorities commonly recommend that blood glucose levels not fall faster than 90 mg% (ie, 5 mmol/L) per hour. The infusion rate of insulin can be reduced as blood glucose levels fall but should not drop below 0.05 U/kg/h to prevent any recurrence of ketosis. Do not discontinue infusion until subcutaneous (SC) insulin has been given when the child has recovered. If blood glucose falls below 120 mg% (ie, 7 mmol/L), increase the concentration of infused glucose to prevent hypoglycemia. Ketosis clears more quickly if insulin infusions are prolonged for 36 hours or more.

In cases of mild-to-moderate diabetic ketoacidosis where the patient is able to tolerate oral fluids, giving repeated (hourly) SC injections of regular or fast-acting analogue insulins in a dose of 0.1U/kg is possible. This is as effective as intravenous insulin.[37, 38]

Electrolyte replacement

  • Potassium: Patients with DKA always have a total body deficit of potassium. After initial resuscitation and if serum/plasma levels are below 5 mEq/L or a good renal output has been maintained, add potassium to all replacement fluids. Table 2 provides examples of infusion concentrations as mEq/L for differing degrees of potassium status. Potassium chloride most commonly is administered. This theoretically could make the acidosis worse, but no evidence indicates that administration of other potassium salts such as phosphate or acetate is more effective.
  • Bicarbonate: Although metabolic acidosis may be severe, no evidence supports administration of IV sodium bicarbonate to improve outcomes; on the contrary, the evidence indicates that IV bicarbonate may cause harm and delay recovery.[39, 40] Failure of the acidosis to improve with treatment more likely reflects inadequate fluid and insulin replacement. The only justification for using IV bicarbonate is acidosis sufficiently severe to compromise cardiac contractility.
  • Other electrolytes: Although patients usually have an absolute deficit of phosphate and magnesium, no evidence indicates that either needs to be replaced in patients with diabetic ketoacidosis.

Table 3. Infusion Rates of Potassium Chloride (Open Table in a new window)

Serum/Plasma K+ (mEq/L)Potassium Chloride (KCL) Dose in Infusion Fluids
< 2.5 mEq/LCarefully monitored administration of 1 mEq/kg body weight by separate infusion over 1 h
2.5-3.5 mEq/L40 mEq/L
3.5-5 mEq/L20 mEq/L
5-6 mEq/L10 mEq/L (optional)
Over 6 mEq/LStop K+ and repeat level in 2 h

Regular assessment

Attention to detail is important to achieving a good outcome. Specifically designed recording charts (see images below) make the process of care much easier. Ideally, these charts include all important measurements of clinical and biochemical status, fluid balance, and insulin prescription.

Page 1 (of 4), diabetic ketoacidosis (DKA) treatmePage 1 (of 4), diabetic ketoacidosis (DKA) treatment and results flow chart. Page 2 (of 4), diabetic ketoacidosis (DKA) treatmePage 2 (of 4), diabetic ketoacidosis (DKA) treatment and results flow chart. Page 3 (of 4), diabetic ketoacidosis (DKA) treatmePage 3 (of 4), diabetic ketoacidosis (DKA) treatment and results chart. Page 4 (of 4), diabetic ketoacidosis (DKA) treatmePage 4 (of 4), diabetic ketoacidosis (DKA) treatment and results flow chart.

Frequent review of neurologic status, at least hourly (or any time a change in level of consciousness is suspected), is essential during the first 12 hours of diabetic ketoacidosis treatment. Promptly treat any suspected cerebral edema.

Links to consensus guidelines for diabetes ketoacidosis management in children include the following:

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Consultations

  • Consult a neurosurgeon if cerebral edema is suspected.
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Diet

  • Once the child has recovered, he or she can resume a normal diet.
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Contributor Information and Disclosures
Author

William H Lamb, MBBS, MD, FRCP(Edin), FRCP, FRCPCH  Clinical Lecturer, Department of Child Health, The General Hospital, Bishop Auckland, UK

William H Lamb, MBBS, MD, FRCP(Edin), FRCP, FRCPCH is a member of the following medical societies: British Medical Association, British Society of Paediatric Endocrinology and Diabetes, International Society of Pediatric and Adolescent Diabetes, Royal College of Paediatrics and Child Health, and Royal College of Physicians

Disclosure: Roche Diabetes Care Honoraria Speaking and teaching

Specialty Editor Board

G Patricia Cantwell, MD, FCCM  Professor of Clinical Pediatrics, Chief, Division of Pediatric Critical Care Medicine, University of Miami, Leonard M Miller School of Medicine; Medical Director, Palliative Care Team, Director, Pediatric Critical Care Transport, Holtz Children's Hospital, Jackson Memorial Medical Center; Medical Manager, FEMA, Urban Search and Rescue, South Florida, Task Force 2; Pediatric Medical Director, Tilli Kids – Pediatric Initiative, Division of Hospice Care Southeast Florida, Inc

G Patricia Cantwell, MD, FCCM is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Heart Association, American Trauma Society, National Association of EMS Physicians, Society of Critical Care Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

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.

Barry J Evans, MD  Assistant Professor of Pediatrics, Temple University Medical School; Director of Pediatric Critical Care and Pulmonology, Associate Chair for Pediatric Education, Temple University Children's Medical Center

Barry J Evans, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Mary E Cataletto, MD  Director of Children's Sleep Services, Winthrop Sleep Disorders Center, Mineola, NY; Professor of Clinical Pediatrics, State University of New York at Stony Brook, Stony Brook, NY

Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Chest Physicians

Disclosure: Shering Plough Pharmaceuticals Honoraria Consulting

Chief Editor

Timothy E Corden, MD  Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin

Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, and Wisconsin Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

The author would like to thank Debbie Matthews and Tim Cheetham for reading the manuscript and for all their support.

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A graphical representation of the ECG changes of hypokalemia.
A graphical representation of the ECG changes of hyperkalemia (due to overcorrection of potassium loss).
Glasgow Coma Scale, modified for age of verbal response.
Page 1 (of 4), diabetic ketoacidosis (DKA) treatment and results flow chart.
Page 2 (of 4), diabetic ketoacidosis (DKA) treatment and results flow chart.
Page 3 (of 4), diabetic ketoacidosis (DKA) treatment and results chart.
Page 4 (of 4), diabetic ketoacidosis (DKA) treatment and results flow chart.
Carbs for Kids-Count Them In: The Constant Carbohydrates Diet.
Diabetes Sick Day Rules.
Taking Diabetes Back to School.
Table 1. Clinical Assessment of Dehydration
Mild < 3%Moderate



3-8%



Severe 8% and



Shock >10%



AppearanceThirsty, alertThirsty lethargicDrowsy, cold
Tissue turgorNormalAbsentAbsent
Mucous membranesMoistDryVery dry
Blood pressureNormalNormal or lowLow for age
PulseNormalRapidRapid and weak
EyesNormalSunkenGrossly sunken
Anterior fontanelleNormalSunkenGrossly sunken
Table 2. Suggested daily maintenance fluid replacement rates.
WeightInfusion rate
0-12.9 kg80 mL/kg/24 h
13-19.9 kg65 mL/kg/24 h
20-34.9 kg55 mL/kg/24 h
35-59.945 mL/kg/24 h
Adult (>60 kg)35 mL/kg/24 h
Table 3. Infusion Rates of Potassium Chloride
Serum/Plasma K+ (mEq/L)Potassium Chloride (KCL) Dose in Infusion Fluids
< 2.5 mEq/LCarefully monitored administration of 1 mEq/kg body weight by separate infusion over 1 h
2.5-3.5 mEq/L40 mEq/L
3.5-5 mEq/L20 mEq/L
5-6 mEq/L10 mEq/L (optional)
Over 6 mEq/LStop K+ and repeat level in 2 h
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