/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/cpg/,/clinical/cckm-tools/content/cpg/diabetes-and-endocrinology/,/clinical/cckm-tools/content/cpg/diabetes-and-endocrinology/related/,

/clinical/cckm-tools/content/cpg/diabetes-and-endocrinology/related/name-100682-en.cckm

201705121

page

100

UWHC,UWMF,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Clinical Practice Guidelines,Diabetes and Endocrinology,Related

Pediatric ED Diabetic Ketoacidosis (DKA) Algorithm

Pediatric ED Diabetic Ketoacidosis (DKA) Algorithm - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Diabetes and Endocrinology, Related


Pediatric Emergency Dept. Diabetic Ketoacidosis (DKA) Algorithm
Patient presentation with suspected DKA
Diabetes – Pediatric/Adult – Inpatient/Ambulatory Guideline
Mild Moderate Severe
Severity of
Dehydration
Initial Lab
Tests and
Evaluation
IV Fluids
(1
st
Hour)
Lab Results
Initial Labs: Glucose, POC; Potassium, whole blood; Sodium, whole blood; BMP (sodium, potassium, chloride,
bicarbonate, anion gap, glucose, BUN, creatinine, calcium); pH; Magnesium; Phosphate; Urinalysis; Consider Hgb A1C if
not completed in the last 90 days
Evaluation:
ξ Perform hourly neurological exams and vital signs
ξ Evaluate hydration status
ξ Perform continuous electrocardiogram monitoring to assess for hyper- or hypokalemia and arrhythmias
ξ Stop patient’s insulin pump (if applicable)
Normal saline 10 mL/kg Normal saline 20 mL/kgNormal saline maintenance
pH > 7.25 and CO2 > 15
pH < 7.25 and CO2 < 15
If only one parameter abnormal, consider anion gap and clinical appearance.
Alert and oriented patients ONLY
If any mental status concerns, suspect cerebral
edema and intervene immediately
1. Consult Pediatric Endocrinology to discuss:
ξ Last insulin dose (long-acting and short-acting)
ξ Current lab values
ξ Correction factor and patient sick day plans
(see last clinic visit note)
2. Administer subcutaneous insulin lispro (once) based
on discussion with Pediatric Endocrinology. Consider
insulin glargine if patient reports missed dose of long-
acting insulin. Check blood sugar every 2-3 hours and
give correction insulin every 2-3 hours.
3. Administer further 0.9% NS boluses as needed
depending on degree of dehydration. If unable to take
orally, consider starting 0.9% NS with 5% dextrose at
maintenance rate with close attention to glycemic
control.
4. Evaluate disposition. Instruct patient and family to
check blood sugar every 2-3 hours and give correction
insulin every 2-3 hours. Consider providing contact
information for diabetes resources (608-263-6420 or
www.uwhealthkids.org/type1diabetes)
1. Consult PICU if pH < 7.25 and CO2 < 15 OR if one abnormal
parameter and anion gap > 15 mmol/L or clinically unwell.
A consult to Pediatric Endocrinology may be more appropriate if
anion gap < 15 mmol/L and/or patient is well-appearing.
2. Administer IV insulin regular (0.1 units/kg/hr).
Hold if K < 3 mmol/L.
3. Administer 2
nd
Hour IV fluids at 1.5 x maintenance IV fluid
rate according to 2-bag system:
ξ If K > 5.5 mmol/L, 0.9% NS (Bag A) and 0.9% NS with 10%
dextrose (Bag B) given in ratio dependent upon blood
glucose (see table below)
ξ If K < 5.5 mmol/L, 0.9% NS with 20 mEq/L KCl (Bag A) and
0.9% NS with 10 % dextrose and 20 mEq/L KCl (Bag B) given
in ratio dependent upon blood glucose (see table below)
DKA DiagnosedDKA Not Diagnosed
Admit to PICU ASAP
Admit to General Care
Do NOT administer insulin bolus.
Do NOT administer bicarb.
Discharge
References:
1. Wolfsdorf J, Glaser N, Sperling MA, Association AD. Diabetic ketoacidosis in infants, children, and adolescents: A consensus statement
from the American Diabetes Association. Diabetes Care. May 2006;29(5):1150-1159.
2. Kapellen T, Vogel C, Telleis D, Siekmeyer M, Kiess W. Treatment of diabetic ketoacidosis (DKA) with 2 different regimens regarding fluid
substitution and insulin dosage (0.025 vs. 0.1 units/kg/h). Exp Clin Endocrinol Diabetes. May 2012;120(5):273-276.
3. Nallasamy K, Jayashree M, Singhi S, Bansal A. Low-dose vs standard-dose insulin in pediatric diabetic ketoacidosis: a randomized clinical
trial. JAMA Pediatr. Nov 2014;168(11):999-1005.
4. Koves IH, Leu MG, Spencer S, et al. Improving care for pediatric diabetic ketoacidosis. Pediatrics. Sep 2014;134(3):e848-856.
5. Association AD. Professional Practice Committee for the Standards of Medical Care in Diabetes-2016. Diabetes Care. Jan 2016;39 Suppl 1:S107-108.
4. Consider 2
nd
IV for
hourly lab draws:
Glucose, POC; pH;
Electrolytes, whole blood
(sodium, potassium,
chloride, total carbon
dioxide, anion gap)
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Pediatric Emergency Dept. Diabetic Ketoacidosis Algorithm-Supplement
Pediatric DKA - Calculation of Bag A and Bag B Rates
Weight/kg Maintenance Rate 1.5 x Maintenance Rate
(total amount in second hour)
4 kg 16 ml 24 ml
5 kg 20 ml 30 ml
6 kg 24 ml 36 ml
7 kg 28 ml 42 ml
8 kg 32 ml 48 ml
9 kg 36 ml 54 ml
10 kg 40 ml 60 ml
11 kg 42 ml 72 ml
12 kg 44 ml 66 ml
13 kg 46 ml 69 ml
14 kg 48 ml 72 ml
15 kg 50 ml 75 ml
16 kg 52 ml 78 ml
17 kg 54 ml 81 ml
18 kg 56 ml 84 ml
19 kg 58 ml 87 ml
20 kg 60 ml 90 ml
21 kg 61 ml 92 ml
22 kg 62 ml 93 ml
23 kg 63 ml 95 ml
24 kg 64 ml 96 ml
25 kg 65 ml 98 ml
26 kg 66 ml 99 ml
27 kg 67 ml 101 ml
28 kg 68 ml 102 ml
29 kg 69 ml 104 ml
30 kg 70 ml 105 ml
31 kg 71 ml 107 ml
32 kg 72 ml 108 ml
33 kg 73 ml 110 ml
34 kg 74 ml 111 ml
35 kg 75 ml 113 ml
36 kg 76 ml 114 ml
37 kg 77 ml 116 ml
38 kg 78 ml 117 ml
39 kg 79 ml 119 ml
40 kg 80 ml 120 ml
41 kg 81 ml 122 ml
42 kg 82 ml 123 ml
43 kg 83 ml 125 ml
44 kg 84 ml 126 ml
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Pediatric Emergency Dept. Diabetic Ketoacidosis Algorithm-Supplement
Weight/kg Maintenance Rate 1.5 x Maintenance Rate
(total amount in second hour)
45 kg 85 ml 128 ml
46 kg 86 ml 129 ml
47 kg 87 ml 131 ml
48 kg 88 ml 132 ml
49 kg 89 ml 134 ml
50 kg 90 ml 135 ml
51 kg 91 ml 137 ml
52 kg 92 ml 138 ml
53 kg 93 ml 140 ml
54 kg 94 ml 141 ml
55 kg 95 ml 143 ml
56 kg 96 ml 144 ml
57 kg 97 ml 146 ml
58 kg 98 ml 147 ml
59 kg 99 ml 149 ml
60 kg 100 ml 150 ml
61 kg 101 ml 152 ml
62 kg 102 ml 153 ml
63 kg 103 ml 155 ml
64 kg 104 ml 156 ml
65 kg 105 ml 158 ml
66 kg 106 ml 159 ml
67 kg 107 ml 161 ml
68 kg 108 ml 162 ml
69 kg 109 ml 164 ml
70 kg 110 ml 165 ml
71 kg 111 ml 167 ml
72 kg 112 ml 168 ml
73 kg 113 ml 170 ml
74 kg 114 ml 171 ml
75 kg 115 ml 173 ml
76 kg 116 ml 174 ml
77 kg 117 ml 176 ml
78 kg 118 ml 177 ml
79 kg 119 ml 179 ml
80 kg 120 ml 180 ml
81 kg 121 ml 182 ml
82 kg 122 ml 183 ml
83 kg 123 ml 185 ml
84 kg 124 ml 186 ml
85 kg 125 ml (adult rate) 188 ml

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org