Pediatric DKA

Key considerations: Cerebral edema (0.5-1% of peds DKA — highest risk young children and new-onset), Hypoglycemia from over-aggressive insulin, Hypokalemia causing arrhythmia

Cannot miss

Cerebral edema (0.5-1% of peds DKA — highest risk young children and new-onset)
Hypoglycemia from over-aggressive insulin
Hypokalemia causing arrhythmia

Likely diagnoses

New-onset Type 1 DM presenting as DKA
Established T1DM with insulin non-adherence
Insulin pump failure
Intercurrent illness triggering DKA

Red flags

Age <5 years (highest cerebral edema risk)
New-onset diabetes
pH <7.1
Glucose >600
Altered mental status
Headache or behavioral change during treatment (early cerebral edema)
Bicarbonate <5

Workup

history: Polyuria, polydipsia, weight loss, vomiting, abdominal pain, prior diabetes diagnosis, insulin use, intercurrent illness; exam: Dehydration assessment, Kussmaul respirations, fruity breath, mental status, signs of infection; labs: Glucose, BMP (calculate anion gap, corrected sodium), blood gas (venous acceptable), CBC, HbA1c, beta-hydroxybutyrate, UA; ECG if hypokalemia changes suspected; imaging: Head CT only if concern for cerebral edema and clinical deterioration; bedside: Point-of-care glucose, hourly glucose monitoring, cardiac monitoring

Management

immediate: Fluid resuscitation: 10 mL/kg NS bolus over 1 hour ONLY if hemodynamically unstable; Do NOT give aggressive fluids — increases cerebral edema risk; general: Maintenance + deficit replacement over 48 hours with D5 0.9%NS + 40 mEq/L KCl; Insulin: 0.05-0.1 units/kg/hr IV continuous infusion — do NOT give bolus; Start insulin 1-2 hours after fluids, not before; Potassium: always add to fluids, do NOT start insulin if K <3.5; Cerebral edema treatment: mannitol 0.5-1g/kg IV or 3% saline 2.5-5 mL/kg — have at bedside BEFORE starting treatment

Disposition

admit: All peds DKA — ICU if pH <7.1, altered mental status, age <5, or cerebral edema concern; discharge: Never acutely; consults: Pediatric endocrinology, ICU

Clinical pearls

Do NOT give insulin bolus in pediatric DKA — strongly associated with cerebral edema
Cerebral edema typically occurs 4-12 hours after treatment initiation — monitor closely
A normal or falling sodium during DKA treatment is a warning sign of cerebral edema — sodium should rise as glucose falls

Source and review

ISPAD DKA Guidelines 2022. Last reviewed: 2024-11-01