In this section
Diabetic ketoacidosis (DKA) is the combination of hyperglycemia, metabolic acidosis, and ketonaemia. It may be the first presentation for a child with previously undiagnosed diabetes. It can also be precipitated by illness, or poor compliance with taking insulin.
All patients presenting with a blood glucose level (BGL) ≥ 11.1mmol/l should have blood ketones tested on a capillary sample using a bedside OptiumTM meter. If this test is positive (>0.6 mmol/l), assess for acidosis to determine further management. Urinalysis can be used for initial assessment if blood ketone testing is not available.
The biochemical criteria for DKA are:
1. Venous pH
< 7.3 or bicarbonate <15 mmol/l
2. Presence of blood or urinary ketones
If ketones are negative, or the pH is normal in the presence of ketones, patients can be managed with subcutaneous (s.c.) insulin (see '
new presentation, mildly ill' below).
Venous blood sample (place an i.v. line if possible as this will be needed if DKA is confirmed) for the following:
· Ketones, culture (if clinical evidence of infection)
Children and adolescents with DKA should be managed in a unit that has:
Intravenous or oral fluids that may have been given at another facility should be factored into the assessment and calculation of fluid deficit and replacement needs
Commence rehydration with normal saline + potassium (see section 4 below for K+ replacement). The fluid type will need to be adjusted dependent on ongoing glucose, Na and K levels.
Keep nil by mouth (except ice to suck) until alert and stable.
Insert a nasogastric tube if the patient is comatose or has recurrent vomiting; leave on free drainage.
Fluid replacement with normal saline and potassium should continue for at least the first 6 hours. If the blood glucose falls very quickly within the first few hours, or if theBGL reaches 12-15mmol/l, change to normal saline with 5% dextrose and potassium.
Choice of fluid after the initial 6 hours will be influenced by the corrected serum sodium (see below for calculation) and the blood glucose level. Corrected sodium should remain stable or rise as blood glucose level falls. Fluids with a tonicity of
< 0.45% saline should not be used.
Beyond the initial 6 hours, 0.45% NaCl with 5% dextrose and potassium may be used once the BGL is
<12-15mmol/l. However, if hyponatremia is present, if the corrected serum sodium fails to stabilise or rise as the BGL decreases, or if hyperosmolar and concerned about rapid shifts in osmolality, 0.9% saline + dextrose and potassium should be continued.
Aim to keep the blood glucose level between 5 - 12mmol/l.
If the patient is still acidotic, and the BGL is < 5.5 mmol/l or is falling rapidly within the range of 5.5 to 15 mmol/l increase the dextrose concentration in the fluid to 10% (plus normal saline + potassium). . The insulin infusion rate should only be turned down if BGL continues to fall despite use of 10% dextrose. In such patients, a reduction in the rate of insulin to 0.05U/kg/hr may be used, provided that metabolic acidosis continues to improve. In this circumstance this should be discussed with a paediatric endocrinologist.
If the patient becomes hypoglycaemic, manage as per hypoglycaemia section below.
Rehydration may be completed orally after the first 24 - 36 hours if the patient is metabolically stable (this usually coincides with insulin therapy being switched to s.c. injections).
Potassium replacement therapy is required for treatment of DKA. This is because a total body deficit of potassium occurs in DKA and correction of the acidosis in the absence of potassium therapy will usually rapidly result in hypokalaemia. Patients may have hyperkalaemia, hypokalaemia or normokalaemia at presentation, depending on the total body potassium deficit and the degree of acidosis.
Note: Beware the rare entity of hyperglycaemic-hyperosmolar non-ketotic coma. If this is a possibility, insulin should ONLY be used after discussion with local paediatric team and/or paediatric endocrinologist.
Bicarbonate administration is not routinely recommended as it may cause paradoxical CNS acidosis. Continuing acidosis indicates insufficient fluid and insulin replacement. Nonetheless, in rare circumstances, some extremely sick children may benefit from cautious administration (e.g. those with pH
< 7.0 +/- HCO3 < 5mmol/L who require adrenaline for BP support or those with marked hyperkalemia). In these children, small amounts may be given after discussion with the consultant endocrinologist.
HCO3 dose (mmol) = 0.15 x body weight (kg) x base deficit. Give over 30-60 min with cardiac monitoring. Reassess acid base status. Remember risk of hypokalemia.
1. Hyper / Hyponatraemia
Measured serum sodium is depressed by the dilutional effect of the hyperglycaemia. To "correct" sodium concentration, use the following formula:
Corrected (i.e. actual) Na = measured Na + 0.3 (glucose - 5.5) mmol/l
i.e. 3 mmol/l of sodium to be added for every 10 mmol/l of glucose above 5.5 mmol/l.
If Na is > 160 mmol/l, discuss with senior doctor.
If sodium does not rise as the glucose falls during treatment or if hyponatraemia develops, it usually indicates overzealous volume correction and insufficient electrolyte replacement. This may place the patient at risk of cerebral oedema.
If blood glucose falls below 4.0 mol/l and patient is still acidotic, give i.v. 10% dextrose 2-5 ml/kg as a bolus and use a 10% dextrose concentration for ongoing iv fluids (with 0.45% NaCl and K+ supplements). Do not discontinue the insulin infusion.
If hypoglycaemia occurred despite use of 10% dextrose in the preceding 2 or more hours, the rate of the insulin infusion may be decreased to 0.05U/kg/hr as long as ketosis and acidosis are clearing. Continue with a 10% dextrose concentration in i.v. fluids until BGL stable.
If blood glucose falls below 4.0mmol/l and most recent pH is >7.30, oral treatment for hypoglycaemia (jelly beans + 1 serve of complex carbohydrate) can be used instead of an i.v. bolus of dextrose 10%.
3. Cerebral Oedema
Some degree of subclinical brain swelling is present during most episodes of diabetic ketoacidosis. Clinical cerebral oedema occurs suddenly, usually between 6 and 12 hours after starting therapy (range 2 - 24 hr). Mortality or severe morbidity is very high without early treatment.
Slow correction of fluid and biochemical abnormalities. Optimally, the rate of fall of blood glucose and serum osmolality should not exceed 5 mmol/l/hr, but in children there is often a quicker initial fall in glucose. Patients should be nursed head up.
Mannitol 20% 0.5 g/kg (range 0.25--1.0 g/kg) i.v. over 20 minutes. Give immediately when the clinical diagnosis is suspected - do not delay for confirmatory brain scan. The dose can repeated if no initial response after 30 mins - 2 hours
Reduce fluid input by 1/3 in the first instance. Nurse head up
Transfer immediately to ICU level care.
When to admit/consult local paediatric team:
When to consider transfer to tertiary centre:
Information specific to MMC
Children with DKA should be discussed with the paediatric endocrinologist on call at the earliest opportunity.
< 3% dehydration, no acidosis and not vomiting
Investigations for all children newly diagnosed with diabetes
Check blood ketones (bedside test) on all patients presenting with BGL ≥11.1mmol/l.
Additional tests to consider
For children / adolescents who are overweight or have clinical evidence of acanthosis nigricans:
The decision about the individual insulin regimen will be made by the paediatric diabetes team in discussion with the family and child. The regimens outlined below are a guide only and individual clinicians may recommend an alternative approach.
0.25 units/kg of quick-acting insulin s.c. stat.
Standard insulin regimens in newly diagnosed patients may comprise either of the two regimens below:
1. Twice daily injections of a mixture of short and intermediate-acting insulins:
Usually commence with total daily dose (TDD) of 1 unit/kg/day but this may need modification (e.g. less in younger child aged
This is given as 2/3 of TDD in morning, 1/3 of TDD at night. 2/3 of each dose as intermediate-acting insulin, 1/3 as short-acting insulin.
Note: In children who will be starting twice daily injections but who present after 2200 hrs, it may be too late to start with a mixture of intermediate and short acting insulins. In this instance, give 0.25 U/kg short-acting insulin, which may need to be repeated after 4-6 hours, with a snack (depending on BGL,,ketones and interval to breakfast).
2. Multiple daily injections (MDI) of insulin using a long-acting insulin analogue at night and pre-meal injections of rapid-acting insulin analogue
Also start with TDD of ~1.0 U/kg/day.
In general, multiple daily injection regimens offer greater lifestyle flexibility (around mealtimes, sport etc); however the child must be old enough to learn how to administer insulin using a pen device without parental supervision (e.g. at school). This is usually possible with children aged >10 years. Twice daily mixed injections are usually commenced in children
For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.
Diabetes Ambulatory Care Service (DACS) allows for many newly diagnosed children with diabetes to not require hospitalization. Please see relevant paediatric diabetes protocol on MMC intranet policies and procedures site.
Patients with established T1DM who present with hyperglycaemia and ketosis but normal pH, will need additional s.c. insulin to clear their ketones.
(i) Patients on intermittent daily injections of insulin (bd or MDI)
Give 10% of the patient's total daily insulin dose as a sub-cut injection of rapid-acting insulin (this is in addition to usual insulin regimen). Monitor BGL and ketones 1-2 hourly. This dose of rapid-acting insulin can be repeated after 2-4 hours if blood ketones are not
(ii) Patients on insulin pump therapy
Need to assume line failure / blockage has interrupted insulin delivery. Give 20% of the patient's total daily insulin dose as a s.c. injection of rapid-acting insulin (higher dose relative to above patient group is because there is no longer acting insulin 'on board' in pump patients). Once s.c. insulin has been given, ask the patient or family to resite the pump cannula and commence delivery at usual settings. Monitor BGL and ketones 1-2 hourly. For patients on pump therapy, ketones should clear to
Notify local paediatric team or paediatric endocrinologist if there are any management issues that you want to discuss. If discharged home, the family should be advised to check BGLs and ketones regularly and to follow up with their diabetes nurse educator the following day.
Consider transfer when:
Information Specific to RCH
Diabetic educators and the endocrinology team are available for help with management.