UMEM Educational Pearls

Title: Pediatric DKA (submitted by Anthony Roggio, MD)

Keywords: diabetic ketoacidosis, DKA (PubMed Search)

Posted: 3/27/2015 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

ISPAD (International Society for Pediatric and Adolescent Diabetes) Updated their Guidelines for Pediatric Diabetic Ketoacidosis (DKA) in 2014

Fluids:

· Begin fluid repletion with 10-20ml/kg of 0.9% NS over 1-2 hours

· Estimate losses (mild DKA <5%, moderate 5-7%, severe ~10%) and replete evenly over 48 hours

o Use NS, Ringers or Plasmalyte for 4-6 hours

o Afterwards use any crystalloid, tonicity at least 0.45% NaCl

· Add 5% glucose to IV fluid when glucose falls below 250-300mg/dL

Insulin

· No bolus

· Low dose 0.05 - 0.1U/kg/hr AFTER initiating fluid therapy

o higher incidence of cerebral edema in patients given insulin in 1st hour

· Short acting subQ insulin lispro or aspart can be substituted for drip in uncomplicated mild DKA

· Give long acting subQ insulin at least 2 hours before stopping infusion to prevent rebound

Potassium

· If K low (< 3.3): add 40mmol/L with bolus IV fluids (20mmol/L if rate > 10ml/kg/hr)

· if K normal (3.3-5): add 40mmol/L when insulin is started

· If K high (> 5): add 40mEq/L after urine output is documented

Bicarb

· No role for bicarbonate in treatment of Pediatric DKA

o No benefit, possibility of harm (paradoxical CNS acidosis)

Wolfsdorf JI, Allgrove J, Craig ME, et al. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes. 2014;15 Suppl 20:154-79.