Diabetic Ketoacidosis – remember in paediatrics this may be the 1st presentation of diabetes.
- Fluid – are more considered than adults due to the risk of cerebral oedema
- Insulin – WAIT – need 1hr of fluid first
- Paeds – involve them early
- USE the BSPED DKA Management flow charts, calculators and full guidelines for when electrolytes won’t play ball which are all linked below.
DKA Management Calculator (recommended by paediatrics)- HERE
DKA Management Flow Chart – HERE
Full BSPED DKA Guideline – HERE
Confirm DKA
Click here for flowchart if that’s easier for you.
Clinical
- Acidotic Respiration (Kussmaul breathing)
- Dehydration
- Drowsy [Monitor mental state hourly]
- Abdominal Pain/Vomit
Biochemical – should have ALL of following
- Blood Glucose >11mmol/l
-
note children and young people with known diabetes may develop DKA with normal blood glucose levels.
-
- Blood pH <7.3
- Blood Ketone >3mmol/l or urine ketones ++
Severity
- MILD – pH 7.2- 7.29 &/or HCO3< 15
- MODERATE – pH 7.1-7.19 &/or HCO3 < 10
- SEVERE – pH <7.1 &/or HCO3 < 5
Investigations
- Blood Glucose
- U&E
- FBC
- Venous/Capillary Gas
- Blood Ketone
- 0 – 0.5 [Negative – Low]
- 0.6 – 1.5 [Low – Moderate]
- 1.6 – 3 [Moderate]
- >3 [High]
- Chloride, Calcium, Phosphate
- Consider Blood cultures (fever is not part of DKA)
- NEW DIAGNOSIS (and able to get enough blood) – HBA1C, TFT, Coeliac screen
Initial fluid Bolus
- NOT Shocked (but judged to require fluids)- 10ml/kg 0.9% NaCl over 60 min
- Shocked – 20ml/kg 0.9%NaCl over 15 min
- May give further 10ml/kg boluses if required up to total 40ml/kg (then inotrops indicated)
Fluid deficit & Maintenance
DKA Management Calculator (recommended by paediatrics)
- MILD (5% deficit)– pH 7.2- 7.29 &/or HCO3< 15
- MODERATE (7% deficit) – pH 7.1-7.19 &/or HCO3 < 10
- SEVERE (10% deficit) – pH <7.1 &/or HCO3 < 5
Deficit Calculation (ml) = % dehydration x Weight[kg] x 10
-
- 5% deficit = 50ml/kg/48hr
- 7% deficit = 70ml/kg/48hr
- 10% deficit = 100ml/kg/48hr
- Replace over 48 hours – use 0.9% NaCl with 20 mmol KCl in 500 ml
- Initial fluid bolus- what to do?
- Non-Shocked (but requiring fluid) – 10ml/kg [Subtract from total]
- Shocked – resuscitation fluid [DO NOT Subtract from total]
Maintenance
- First 10kg body weight- 100 ml/kg/day
- Second 10kg body weight – 50 ml/kg/day
- Additional kilogram above 20 kg – 20 ml/kg/day
Blood Glucose under 14mmol/l
- Use: 0.9% NaCl + 20mmol KCl + 5% dextose
Sodium Correction – D/W Paeds senior
Insulin
- ONLY Start 1-2hr after fluid therapy begins
- There is no need to start in ED [unless prolonged stay]
- Evidence: Early insulin increases likelihood of Cerebral Oedema
USE: 50 unit Actrapid in 49.5ml 0.9% NaCl [Syringe pump must be used]
Dose
- Insulin infusion – 0.05unit/kg/hour (0.05ml/kg/hour)
- Blood Glucose <14mmol/l – change fluid 0.9% NaCl + 20mmol KCl + 5% dextrose
- Blood Glucose <4mmol/l – Bolus 2ml/kg 10% dextrose
- Blood Glucose not falling – Consider increase to 0.1unit/kg/hr [D/W Paeds]
BSPED Fluid Calculator: BSPED fluid calculator
Full GUIDE: dkap
