Diabetic ketoacidosis (DKA) is the end result of the metabolic
abnormalities resulting from a severe insulin deficiency or
DKA at diagnosis is more common in young children near the age
of five years.
The risk increases gradually in children with
Poor metabolic control
Previous episodes of DKA
Children with psychiatric and eating disorders
Low socioeconomic status
Low parental education and
Infection (viral fever, pneumonia, UTI etc.), Insulin omission
either inadvertently or deliberately, is the cause in most cases.
Children and young people without known diabetes who have
increased thirst, polyuria, recent unexplained weight loss or
excessive tiredness and any of the following:
Nausea or vomiting
Reduced level of consciousness.
Suspect DKA even if the blood glucose is normal in a child with
known diabetes and having above mentioned complains.
1. Acidosis (indicated by blood pH below 7.3 or plasma
bicarbonate below 18 mmol/litre), and
2. Ketonaemia (indicated by blood beta-hydroxybutyrate above 3
mmol/litre) or ketonuria (++ and above on the standard strip
Blood glucose levels are generally high (above 11 mmol/l or 198
mg/dl) but DKA may develop with normal blood glucose.
Urine ketones may be positive long after ketoacidosis has
resolved because the nitroprusside reaction routinely used to
measure urine ketones by dipstick measures only acetoacetate.
During DKA, most excess ketones are β- hydroxybutyrate, which
increases the normal ratio to acetoacetate from 3 : 1 to as high as 8 : 1.
With resolution of the acidosis, β- hydroxybutyrate converts to
acetoacetate,which is excreted into the urine and detected by the
Therefore, persistent ketonuria may not accurately reflect the
degree of clinical improvement and should not be relied on as an
indicator of therapeutic failure.
CLASSIFICATION OF DKA
pH ≥7.1 - MILD or MODERATE DKA
pH ˂7.1 - SEVERE DKA.
FULL CLINICAL ASSESSMENT
1. Consciousness Level-Directly related to degree of acidosis. Hourly
2. Full Examination- Look for signs of
cerebral oedema (headache, irritability, bradycardia,
rising blood pressure, reducing conscious level, N.B.
papilloedema is a late sign.
3. Weigh the child-If this is not possible then use the most recent
clinic weight as a guideline, or an estimated weight from centile charts.
Blood gases (venous or capillary)
Near patient blood ketones (beta-hydroxybutyrate) if available (superior to
+ /- other investigations only if indicated e.g. PCV and full blood count
(leucocytosis is common in DKA and does not necessarily indicate sepsis),
CXR, CSF, throat swab, blood culture, urinalysis, culture and sensitivity etc.
Sepsis should be suspected, if there is
Fever or hypothermia
Give 100% oxygen by face-mask
Insert IV cannula and take blood samples
Cardiac monitor for T wave
Measure blood pressure and heart rate.
If Reduced level of consciousness and vomiting present think
about inserting a NG tube to reduce the risk of aspiration.
Indications for starting fluid
Type of fluid
FLUIDS: Children who are alert, not clinically dehydrated, not
nauseated or vomiting, do not always require IV fluids, even if their
ketone levels are high.
INITIAL FLUID BOLUS: If child is in shock give 10 ml/kg 0.9%
sodium chloride as a bolus.
Do not give further boluses to a child with severe DKA without
discussion with the responsible senior paediatrician.
Volume of fluid
Once circulating blood volume has been restored (child is no
more in shock), calculate fluid requirements as follows:
Requirement = Deficit + Maintenance
Volume of fluid
Assume a 5% fluid deficit in mild or moderate DKA (pH>7.1).
Assume a 10% fluid deficit in severe DKA (pH<7.1).
Weight (kg) Maintenance fluid
<10 2 ml/kg/hour
10-40 1 ml/kg/hour
>40 40 ml/hour
Maintenance – Calculate by using the following
'reduced volume' rules
If more than 20 ml/kg NS bolus has been given
Subtract any additional bolus volumes from the total fluid
calculation for the 48-hour period
ie, if 30 ml/kg bolus has been given then subtract 10 ml/kg from the
Hourly rate = (deficit / 48hr) + maintenance per hour
Weight Hourly rate
20 kg, with pH 7.18 without any fluid bolus
Deficit= 5% x 20 kg = 1000 mls
Rate = 1000÷48= 21ml/hr
Maintenance 1ml/kg/hr = 20 ml/hr
Total rate= 41ml/hr
50 kg, with pH of 6.8 and required 30 ml/kg 0.9%
sodium chloride bolus for circulatory collapse
Deficit= 10% x 50 kg= 5000 mls
10 ml/kg bolus fluid = -500mls=4500 mls
rate=4500÷48= 93.7 ml/hr
Total rate=133.7 ml/hr
Type of fluid
0.9% sodium chloride with 20 mmol potassium chloride in 500
ml (40 mmol per litre) till blood glucose ˃14 mmol/l (252 mg/dl).
Do not give oral fluids to a child who is receiving intravenous
fluids for DKA until ketosis is resolving and there is no nausea or
If oral fluids are given before the 48hr rehydration period is
completed, the IV infusion needs to be reduced to take account
of the oral intake.
0.05 to 0.1 units/kg/hour, 1-2 hours after beginning intravenous
fluid therapy (cerebral oedema is more likely if insulin is started
Once the blood glucose has fallen to 14 mmol/l (252mg/dl), add
glucose to the fluid and think about the insulin infusion rate, as
If ketone levels are < 3 mmol/l
change the fluid to contain 5% glucose
Reduce to or maintain at an insulin infusion rate of 0.05
If ketone levels are > 3 mmol/l
Maintain the insulin infusion rate at 0.05 to 0.1
units/kg/hour to switch off ketogenesis
Change the fluid to contain 10% glucose
Blood glucose ˂ 6 mmol/l (108mg/dl)- increase the glucose
concentration of ivf, and if there is persisting ketosis, continue
insulin with at least 0.05 units/kg/hour.
Blood glucose ˂ 4 mmol/l (72 mg/dl), give a bolus of 2 ml/kg of
10% glucose and increase the glucose concentration of the
infusion. Insulin can temporarily be reduced for 1 hour.
If the blood beta-hydroxybutyrate level is not falling within 6–8
hours in a child with DKA, think about increasing the insulin
dosage to 0.1 units/kg/hour or greater.
Once the pH is > 7.3, ketones are <3, the blood glucose is down to
14 mmol/l (252 mg/dl), and a glucose-containing fluid has been
started, reduce the insulin infusion rate, to 0.05 units/kg/hour.
If acidosis is not correcting, consider the following
Insufficient insulin to switch off ketones
Salicylate or other prescription or recreational drugs
Think about stopping intravenous fluid therapy when ketosis is
resolving and oral fluids are tolerated without nausea or
Start subcutaneous insulin at least 30 minutes before stopping
If the child was using insulin pump therapy, restart the pump at
least 60 minutes before stopping intravenous insulin.
All fluids (except any initial bolus) contain 40 mmol/l potassium
chloride, unless there is evidence of renal failure.
Hypokalaemia (potassium below 3 mmol/litre): think about
temporarily suspending the insulin infusion
“True,” serum sodium=
[ Na+] + (1.6 mEq/L Na+ for every 100 mg/dL glucose in excess of
Corrected sodium levels should rise as blood glucose levels fall
If the child is becoming hypernatraemic, this is not generally a
problem, and is protective against cerebral oedema.
CONTINUOUS EVERY 30 MINUTES
(in children under 2
years with DKA and
children with severe
DKA) [high risk of
HOURLY 2 HRS AFTER
THEN 4 HOURLY
ECG (to detect
(using the modified
Glasgow coma scale)
Heart rate (to
Blood pH and
with input and
Agitation or irritability
Unexpected fall in heart rate
Increased blood pressure and
Signs such as deterioration in
level of consciousness
Abnormalities of breathing
pattern, for example
Pupillary inequality or
Treat immediately with the most readily available
Mannitol (20% 0.5-1 g/kg over 10-15 minutes), or
Hypertonic saline (2.7% or 3% 2.5-5 ml/kg over 10-15
A repeated dose of Mannitol may be required after 2 hours if
there is no response, In addition fluids should be restricted to ½
maintenance rates and inform senior staff immediately.
Hypoglycaemia and hypokalaemia
Systemic Infections: Antibiotics are not given as a routine unless
a severe bacterial infection is suspected.
Aspiration pneumonia- Insert NG tube in vomiting child with
AVOIDING FUTURE EPISODES OF
Discuss with family members or carers (if appropriate) the
factors that may have led to the episode.
Think about the possibility of non-adherence to therapy in
children and young people with established type 1 diabetes who
present with DKA, especially if the DKA is recurrent.
Advise how to reduce the risk of future episodes. In particular, advise
them of the importance of managing intercurrent illnesses.
Provide appropriate diabetes education and practical information
Emotional and psychological well-being assessment who present
with frequent episodes of diabetic ketoacidosis over a relatively
short time (previously known as 'brittle diabetes').
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