Suspected Pediatric DKA
Child with hyperglycemia, ketosis, and acidosis
All Pathways
PediatricsEmergency
Pediatric Diabetic Ketoacidosis (ISPAD 2022)
Pediatric Diabetic Ketoacidosis (ISPAD 2022): Suspected Pediatric DKA → Confirm DKA Diagnosis → Initial Resuscitation → Fluid Replacement (Hours 1-2) → ...
Pathway Overview
11 steps
Algorithm Steps
11 total
01Start 02Action Confirm DKA Diagnosis
Laboratory criteria for DKA
- Blood glucose >200 mg/dL (11 mmol/L)
- Venous pH <7.3 or HCO3 <18 mmol/L
- Ketonemia or ketonuria
- SEVERITY:
- • Mild: pH 7.2-7.3, HCO3 10-18
- • Moderate: pH 7.1-7.2, HCO3 5-10
- • Severe: pH <7.1, HCO3 <5
03Action Initial Resuscitation
Stabilize circulation and begin monitoring
- Obtain IV access x2 (labs + fluids)
- Weigh patient (use actual weight for calculations)
- Assess degree of dehydration (5-10%)
- If SHOCK: NS 10-20 mL/kg bolus over 20-60 min
- May repeat to restore perfusion (max ~30 mL/kg in first hour)
- Start monitoring: Neuro checks q1h, vitals, I/O
- Insert Foley if impaired consciousness
04Action Fluid Replacement (Hours 1-2)
Careful rehydration to avoid cerebral edema
- Calculate fluid deficit: Weight × % dehydration × 10
- Replace deficit over 24-48 hours (not faster)
- Initial rate: ~1.5-2× maintenance
- Use NS or balanced solution initially
- Switch to NS with K+ once urinating
- DO NOT exceed 1.5-2× maintenance rate
05Action Insulin Infusion
Start 1-2 hours after fluid resuscitation begins
- Regular insulin: 0.05-0.1 units/kg/hr IV
- Start AFTER initial fluid bolus (1-2 hr delay)
- DO NOT give insulin bolus in children
- Target glucose decrease: 50-90 mg/dL/hr
- If glucose falling faster, increase dextrose
- Maintain infusion until ketosis resolves (pH >7.3, HCO3 >18)
06Decision Glucose <250-300 mg/dL?
Add dextrose when glucose falls
07Action Add Dextrose to Fluids
Maintain glucose while continuing insulin
- Change to D5-NS or D10-NS
- Continue insulin infusion
- Goal: Maintain glucose 150-250 mg/dL
- Continue until ketosis resolves
- Do NOT stop insulin until gap closed
08Action Ongoing Monitoring
Frequent reassessment required
- Glucose: hourly
- Electrolytes, BUN, pH: every 2-4 hours
- Neuro checks: hourly for first 12 hours
- I/O: strict monitoring
- Calculate anion gap (closes before HCO3 normalizes)
09Outcome DKA Resolved
Transition to subcutaneous insulin
- Resolution criteria: pH >7.3, HCO3 >18, anion gap normal, tolerating PO
- Give SC insulin 15-30 min before stopping IV insulin
- Transition to age-appropriate insulin regimen
- Diabetes education before discharge
- Path rejoins step 08Shared downstream outcome
10Warning ⚠️ CEREBRAL EDEMA
Watch for neurologic deterioration
- RISK FACTORS: Age <5, new-onset, severe acidosis, rapid correction
- SIGNS: Headache, altered mental status, bradycardia, hypertension
- Cushing triad, posturing, pupil changes
- TREATMENT:
- • Elevate head of bed 30°
- • Reduce fluid rate by 1/3
- • Mannitol 0.5-1 g/kg IV over 20 min
- • OR Hypertonic saline 3% 2.5-5 mL/kg over 15-30 min
- • Intubate if needed (avoid hypocapnia)
11Action Potassium Replacement
Critical - K+ drops with insulin/pH correction
- Add K+ to fluids once K+ <5.5 and urinating
- K+ 4.5-5.5: 20 mEq/L
- K+ 3.5-4.5: 40 mEq/L
- K+ <3.5: 40-60 mEq/L (delay insulin if <3)
- Use KCl + K-phosphate (or K-acetate)
- Check K+ every 2-4 hours
Guideline Source
ISPAD Clinical Practice Consensus Guidelines 2022: DKA and HHS
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Cerebral edema risk higher in children - monitor closely
- Fluid calculations vary by severity and dehydration
- Does not address HHS in detail
Applicable Regions
USEU
Version 1Next review: 2027-01-11
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Related Resources
Frequently Asked Questions
What is the Pediatric Diabetic Ketoacidosis (ISPAD 2022)?
The Pediatric Diabetic Ketoacidosis (ISPAD 2022) is a emergency clinical algorithm for Pediatrics. It provides a structured decision tree to guide clinical decision-making, based on ISPAD Clinical Practice Consensus Guidelines 2022: DKA and HHS.
What guideline is the Pediatric Diabetic Ketoacidosis (ISPAD 2022) based on?
This algorithm is based on ISPAD Clinical Practice Consensus Guidelines 2022: DKA and HHS (DOI: 10.1111/pedi.13406).
What are the limitations of the Pediatric Diabetic Ketoacidosis (ISPAD 2022)?
Known limitations include: Cerebral edema risk higher in children - monitor closely; Fluid calculations vary by severity and dehydration; Does not address HHS in detail. Individual patient factors may require deviation from these recommendations.
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