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Pediatric DKA – Spoon-Feed Version

July 26, 2021

Written by Clay Smith

Spoon Feed
Managing pediatric DKA requires fluid, insulin, intense monitoring, and being ever watchful for cerebral edema. This covers best practices.

Why does this matter?
DKA in children is a common and serious health issue. It occurs mainly in children with type 1 diabetes, and is present in 30% of those with a new diagnosis and occurs in 6-8% per year thereafter. This is a critical care diagnosis we need to be really good at managing.

The sickest kids we can actually help

Clinical Features

  • We’re familiar with polyuria, polydipsia, weight loss, and fatigue.

  • In younger, incontinent children, polyuria is much easier to miss.

  • Once DKA occurs, vomiting, headache, and abdominal pain are common.

  • BP is usually normal. Hypertension is relatively common, despite serious volume depletion; it’s related to counterregulatory hormones, high ADH, and is not at all reassuring. It is associated with cerebral edema.

  • As disease progresses, patients become more altered and Kussmaul respirations occur.


  • Hyperglycemia >200 mg/dL

  • Acidosis: bicarbonate <15 meq/L, pH <7.3*, beta-hydroxybutyrate > 30 mg/dL (3 mmol/L), or urine ketones moderate to large

  • Check a pregnancy test when indicated. Corrected serum Na = measured sodium [1.6 (glucose 100)/100]. Acute kidney injury is common. Elevated BUN is associated with cerebral edema. Hemoglobin A1C can help determine longer-term glucose control. Potassium may measure high from ion shift to the extracellular space, but patients are always total body potassium depleted. Non-specific leukocytosis is common.

Treatment – you may want to check this DKA protocol from TREKK.ca

  • Fluid – A 10-20 mL/kg NS bolus is fine to give and won’t cause cerebral edema. There is debate over NS vs LR in children.

    • Give 0.9% or 0.45% saline by infusion after that – 1.5x maintenance IV fluid rate if pH > 7.1; 2x MIVF rate if ≤ 7.1.

    • Add electrolytes: When serum potassium drops below 5 meq/L, add 20 meq/L KPO4 and 20 meq/L K acetate.

    • Add dextrose. We use the two-bag method: 0.45% saline + electrolytes + D10 in bag 1; 0.45% saline + electrolytes + no dextrose (D0) in bag 2. When glucose > 300 mg/dL, give all the fluid rate without dextrose. When glucose 200-300, give half the IV fluid rate as D10, half as D0 (effectively equals D5). When glucose <200, give all fluid with D10.

  • Insulin – Don’t bolus insulin in children. I see this mistake all the time. Please don’t do this.

  • Try not to intubate these kids. They have very high minute ventilation, and if you don’t keep up, they will have potentially fatal respiratory + metabolic acidosis.

  • Try to avoid central lines, as they are at higher risk of DVT when used in children with DKA.

  • These children need hourly glucose checks and Q2-3h VBGs and Q3-4h BMPs.

  • Most children will get admitted; if severe acidosis is present, admit to the ICU. If you need to transfer the patient, a skilled pediatric critical care transport team is highly recommended.

Cerebral Edema

  • This occurs in <1%. It is more common in younger, more acutely ill patients with more profound metabolic derangements. It has nothing to do with fluid tonicity or rate. Some studies have shown an association with sodium bicarbonate boluses.

  • This is a clinical diagnosis, based on mental status and vital signs. It is not a CT diagnosis. You can get a head CT later, but ALWAYS treat first before going to CT. Clinical signs are: worsening headache, altered mental status, age-inappropriate incontinence, Cushing’s triad.

  • Treatment is 3% saline 3-5mL/kg** rapidly (our protocol is over 10 minutes) or mannitol 0.5-1 g/kg (article has a typo and says mg/kg, which is incorrect). I would recommend 3% over mannitol.

* Correction: original post said pH <3.
** Correction: original post said 3-5mL and should be 3-5 mL/kg.

Managing Diabetic Ketoacidosis in Children. Ann Emerg Med. 2021 May 6;S0196-0644(21)00160-8. doi: 10.1016/j.annemergmed.2021.02.028. Online ahead of print.

What are your thoughts?