Pediatric DKA

Key considerations: Cerebral edema (most feared complication), Severe hypokalemia, Cardiac arrhythmia from electrolyte derangement

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history: Polyuria, polydipsia, weight loss, nocturia (new onset); Duration of symptoms; Insulin adherence and pump issues (known diabetic); Precipitant: illness, missed doses, stress; Abdominal pain and vomiting (common in DKA — mimics surgical abdomen); Prior DKA episodes; exam: Mental status assessment (baseline and serial); Respiratory pattern: Kussmaul breathing; Dehydration assessment: mucous membranes, skin turgor, capillary refill; Fruity breath odor; Abdominal exam (DKA causes abdominal pain — resolves with treatment); labs: BMP: glucose, Na, K, bicarb, BUN, Cr, Ca, Phos, Mg; VBG or ABG: pH and pCO2; Serum beta-hydroxybutyrate (better than urine ketones); Corrected sodium: add 1.6 mEq for every 100mg/dL glucose >100; CBC (leukocytosis common in DKA without infection); HbA1c (new diagnosis or adherence assessment); Urinalysis; imaging: CT head IMMEDIATELY if signs of cerebral edema (headache, altered mental status, bradycardia, hypertension during treatment); bedside: Hourly glucose monitoring; Hourly neurological checks; Strict I&Os; Continuous cardiac monitoring

immediate: 10-20mL/kg NS bolus ONLY if hemodynamically unstable; Do NOT give large fluid boluses (cerebral edema risk); Start IV fluids at 1-1.5x maintenance with 0.45-0.9% NS; Do NOT start insulin for at least 1 hour after starting fluids; Check potassium BEFORE starting insulin; general: DKA severity: mild (pH 7.2-7.3), moderate (pH 7.1-7.2), severe (pH <7.1); Correct dehydration slowly over 24-48 hours; AVOID bicarb administration (increases cerebral edema risk); specific: diagnosis: Moderate-severe DKA; steps: NS bolus 10mL/kg ONLY if signs of shock, otherwise start maintenance fluids; Insulin drip at 0.05-0.1 units/kg/hr — start after 1 hour of fluids and K>3.3; Add potassium to fluids when K<5.5 and patient is voiding; Add dextrose to fluids when glucose <300 (D5 0.45% NS); Goal: glucose decrease no faster than 50-100mg/dL/hour; diagnosis: Cerebral edema; steps: EMERGENCY: mannitol 0.5-1g/kg IV over 15 min OR hypertonic saline 3% 5mL/kg IV; Elevate head of bed 30 degrees; Reduce IV fluid rate by one-third; Emergent CT head; Neurosurgery consult; Intubation if deteriorating (avoid hyperventilation — target normal CO2)

admit: All pediatric DKA patients require admission; Severe DKA: PICU for insulin drip and hourly monitoring; Moderate DKA: monitored bed; New onset diabetes: endocrinology consult and diabetes education; discharge: DKA patients are NOT discharged from the ED; Transition to subcutaneous insulin when: tolerating PO, pH >7.3, bicarb >15, anion gap closed; consults: Pediatric endocrinology — all DKA patients; PICU for severe DKA or cerebral edema; Social work if adherence concerns

Do NOT aggressively fluid bolus pediatric DKA — cerebral edema risk. Only bolus for hemodynamic instability. Goal is SLOW rehydration over 24-48h
Cerebral edema warning signs during treatment: headache, altered mental status, bradycardia, hypertension, pupil changes — have mannitol at bedside
Corrected sodium should RISE during DKA treatment — if corrected Na is falling, cerebral edema risk is increasing
Never give bicarbonate in pediatric DKA — increases cerebral edema risk with no proven benefit
Two-bag system: one bag with NS (no dextrose), one with D10 NS — titrate ratio to control glucose while maintaining insulin drip

ISPAD DKA Guidelines 2022, ADA Standards of Care 2024, Pediatric Emergency Medicine (Fleisher & Ludwig). Last reviewed: 2024-11-01