This document provides guidelines for managing diabetic ketoacidosis (DKA) in children. It outlines recommendations for initial fluid bolus and hydration, monitoring of electrolytes and glucose during treatment, use of bicarbonate and insulin therapy, and monitoring of vital signs and lab values. It also describes cerebral edema as a potential complication of DKA and recommends reducing fluid administration rates and using mannitol or hypertonic saline if cerebral edema develops.

1. G.ERIC MD4

2.  l. Initial fluid bolus should be determined based on
blood pressure and capillary refill
 • Administer 10-20 ml/kg of normal saline bolus over one hr
 • If hypovolemia present, repeat normal saline for another
hr
 2. Calculate fluids based on 10% dehydration, not
exceeding 4000 ml/m2/day. Infuse 0.45% saline until blood
sugar is
 300 mg/dl Dextrose containing fluid (5%) should be added
once the blood glucose fall below 250-300 mg/dl and 10%
 glucose is administered when glucose is <180 mg/ di.
 3. Potassium (20-40 mEq/1 KCl) is added once urine flow is
established and serum K+ is <5.5 mEq/1

3.  B. Use of bicarbonate
 l. Bicarbonate is not used routinely in management of
ketoacidosis
 2. Therapy with sodium bicarbonate is considered if pH does
not improve and arterial pH remains <7.0 (or venous pH <6.9)
 and serum bicarbonate is <5-10 mEq/1
 3. Calculate deficit as follows: Total deficit= (Expected
bicarbonate - actual bicarbonate) x 0.6 x patient weight in kg
 4. Plan half correction of deficit in IV fluid over 24 hr,
targeting total bicarbonate 25 mEq/1 (27 mEq/1 for venous
blood)
 5. Discontinue bicarbonate in IV fluids when serum
bicarbonate reaches 􀁡10 mEq/L and serum pH >7.1

4.  C. Insulin therapy
 l. Following initial hydration, start insulin drip at 0.1 units/kg/hr. If
patient is a known diabetic and has received insulin
 subcutaneously, start at lower insulin dose (0.05 U /kg/hr)
 2. When blood glucose is <300 mg/di, change IV fluids to 5% dextrose with
0.45 saline
 3. If blood glucose drops to <180 mg/ dl, despite 5% dextrose, change IV
fluid to 10% dextrose in 0.45 saline
 4. If blood glucose drops to <150 mg/ di, reduce insulin drip in decrements
of 0.02 unit/kg/hr
 5. The rate of fall of plasma glucose should be 80-100 mg/ dl/hr or 40 mg/
dl/hr in the presence of severe infection. If there is
 no change in plasma glucose in 2-3 hr, increase the insulin infusion to 0.15
U/kg/hr
 6. When patient is acidotic and ketotic, do not decrease insulin infusion
below 0.05 U /kg/hr and do not discontinue insulin
 infusion until after subcutaneous insulin has been given
 7. Monitor blood glucose every 30 minutes when changing insulin drip, or if
blood glucose drops to <150 mg/ di
 8. Insulin must be continued until pH >7.36 or serum bicarbonate is >20
mEq/1

5.  D. Monitoring
 l. Monitor vital signs every hr; neurological
signs every 1 -2 hr
 2. Fluid balance: intake and output monitored
hourly
 3. Blood sugar, electrolytes pH, bicarbonate:
initially 1-2 hr, then every 4 hr
 4. Calcium, phosphate and magnesium every 12 hr
 5. Also send for glycated hemoglobin; lipid profile;
insulin autoantibodies
 6. Screen for infections with appropriate cultures,
X-rays

6.  Symptoms
 Abdominal pain
 Nausea and vomiting
 Polyuria
 Shortness of breath
 Polydipsia
 Physical findings
 Tachycardia
 Dry mucous
membrane, reduced
skin turgor,
hypotension
 Tachypnea, Kussmaul
respiration,
respiratory distress
 Abdominal
tenderness
 Lethargy, cerebral
edema, coma

7.  Cerebral Edema
 This is complications of OKA, is characterized by
headache,
 bradycardia, altered neurological status and
desaturation
 in an otherwise improving child. The condition most
 commonly occurs during the first 5-15 hr of therapy.
The
 rate of fluid administration should be reduced. Either IV
 mannitol (0.25-1 g/kg) over 20 min) or hypertonic (3%)
 saline (5-10 ml/kg over 30 min) is given to reduce
edema