Overview Algorithm for the Management of
Children and Young People under the age of
18 years with Diabetic Ketoacidosis
Version 2 - 2024-07-22
Clinical Signs:
- Dehydration
- Kussmaul breathing
Clinical History: - Ketotic smell Biochemistry:
- Polyuria/polydipsia - Lethargy, drowsiness - Hyperglycaemia
- Weight loss (>11mmol/L)
- Abdominal pain - Acidaemia (pH<7.3)
- Weakness Confirm diagnosis - Ketosis (blood ketones
- Vomiting DIABETIC KETOACIDOSIS >3mmol/L or urine
- Confusion ketones ++)
Call senior staff
pH <7.1 = Severe DKA (10% dehydration
pH <7.2 = Moderate DKA (5% dehydration)
pH <7.3 = Mild DKA (5% dehydration)
- Tachycardia
- Prolonged central capillary refill
- Poor peripheral pulses
- Hypotension (late sign)
Is the
Yes patient No
shocked?
Resuscitation Slow Bolus
Airway +/- NG tube - 10mL/kg bolus 0.9% Sodium
Breathing 100% O2 Chloride or Plasma-Lyte 148 over
Intravenous therapy 30 min
Circulation
- 10mL/kg bolus 0.9% Sodium - Calculate fluid requirements: [Link]
Chloride or Plasma-Lyte 148 - Use fluids (0.9% Sodium Chloride or Plasma-Lyte 148)
- Repeat until circulation restored with 40 mmol/L potassium Signs of cerebral oedema:
(check serum K+ in normal range and urine output first) - Headache, irritability
- By 40mL/kg discuss with senior - Slowing HR
doctor and consider inotropes - Start insulin at 0.05 or 0.1 Units/kg/hour 1-2 hours - Reduced GCS / coma
- Signs of raised ICP
after starting fluids - Others as show on care pathway
Acidosis Features of
failing to cerebral
improve? Observations oedema?
- Hourly blood glucose
- 1-2 hourly blood ketones
- Hourly neuro obs and fluid balance Management of Cerebral Oedema
Management of Persisting Acidosis
- Check electrolytes at 2 hours, then 4 hourly
- Give 5mL/kg 2.7% Sodium Chloride
- Re-evalutate fluid balance - may OR 20% Mannitol 2.5 - 5 mL/kg
require further resus fluid
- Call senior staff
- Check insulin rate and running
Blood - Restrict IV fluids by 50%
properly glucose
- Consider sepsis and other <14mmol/L - Refer to care pathway for further
differentials as per care pathway actions
- Consider restarting protocol
Blood * Excluding boluses, fluids for DKA should be
- Change fluids* to contain 5% glucose 0.9% Sodium Chloride / Plasma-Lyte 148
glucose
<6mmol/L - Continue monitoring as above with 40 mmol/L potassium. This fluid should
also contain glucose as indicated in the care
pathway once the blood glucose falls.
Management of Falling Blood Resolution of DKA
Glucose - Clinically well, tolerating oral fluids, blood ketones <1mmol/L or pH normal
- Change fluids* to contain 10% - Start S/C insulin THEN stop IV insulin 1 hour later
glucose
- Do not reduce insulin below 0.05
Units/kg/hour if ketones >1
mmol/L
This algorithm is a summary of the main care pathway and should not be considered as a complete guide
- If glucose falls below 4mmol/L to the management of paediatric DKA.
refer to care pathway for
management of hypoglycaemia Refer to the main care pathway at the earliest opportunity by visiting [Link] or the BSPED
guidelines page.