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Diabetes mellitus and surgery
The biochemical criteria for diagnosis of DKA are:
Children with hyperglycaemia (Blood glucose level (BGL) >11 mmol/L) +/- ketosis who are not acidotic can be managed with subcutaneous insulin (see Diabetes mellitus,
new presentation, mildly ill).
Hyperglycaemic children with altered conscious state who are not acidotic (pH of ≥7.3) and have little to no ketonaemia may have hyperglycaemic-hyperosmolar non-ketotic coma. If this is a possibility, insulin should ONLY
be given after discussion with local paediatric team and/or paediatric
History and examination are directed towards potential precipitants, assessment of severity, and detecting complications of DKA.
Weigh child – compare to recent weight if available.
Children and adolescents with DKA should be managed in a unit that has:
Bloods - Insert an IV when taking bloods
Consider ECG if potassium results will be delayed
Once DKA is confirmed, the following biochemical monitoring should be put in place to guide ongoing management. These will continue until resolution of DKA:
Sections below include:
Assessment and ABC
IV access and initial bloods including VBG
Start rehydration fluids
Nurse head up
Document passage of urine (ask child to void)
BGL and bedside ketones
Neurological observations, VBG,
VBG and bedside ketones
UEC (must check serum potassium within 1 hour of starting insulin infusion)
Serum calcium, magnesium, phosphate
Serum calcium, magnesium, phosphate
Continue the following hourly:
Continue the following 1-2 hourly:
Continue the following 2-4 hourly:
Children with DKA will be dehydrated. Clinical estimates of fluid deficits are subjective and often inaccurate thus most children can initially be commenced on the “mild” or “moderate” fluid rate (see below).
A 10 mL/kg 0.9% sodium chloride bolus can be given to children who are tachycardic with delayed central capillary refill.
Commence rehydration with isotonic fluid eg 0.9% sodium chloride.
Keep nil by mouth until child is alert and acidosis has resolved.
Intravenous or oral fluids that have been given at another facility may need to be factored into the assessment and calculation of fluid deficit and replacement.
Frequent monitoring of electrolytes, glucose, and osmolality will guide fluid composition and infusion rates. Fluids containing 0.9% sodium chloride should be continued for at least the first 6 hours.
The three key parameters to monitor and manage are:
Osmolality can be calculated using the following formula:
Osmolality = 2 x (serum sodium + serum potassium) + glucose + urea
Measured sodium is depressed by the dilutional effect of hyperglycaemia
Corrected sodium can be calculated with this formula:
Corrected sodium = measured sodium + 0.3 x (glucose – 5.5) mmol/L
ie 3 mmol/L sodium to be added for every 10 mmol/L of glucose above 5.5 mmol/L.
IV fluids can be ceased once pH and bicarbonate have normalised and the child is able to tolerate oral intake (this usually coincides with insulin being changed to subcutaneous injections).
IV rehydration should be commenced prior to starting an insulin infusion.
To make up the insulin infusion:
Initial insulin infusion rates
The most important complications of DKA and its treatment are:
A BGL of
<4.0 mmol/L should be treated with additional glucose as below.
Assess for underlying infections and consider antibiotics after obtaining relevant cultures if appropriate.
In children with known T1DM the most common cause of DKA is omission or significant reduction in recent insulin doses.
If the acidosis is not correcting, consider the following:
All children with DKAAll newly diagnosed diabetes mellitusHyper/hyponatraemia
Intensive care monitoring is recommended for
The care required is beyond the level of comfort or resources of the local hospital. Children and adolescents with DKA should be managed in a unit that has:
For emergency advice and paediatric or neonatal ICU transfers, call
the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137
Children with DKA should be discussed with the paediatric endocrinologist on-call
Last Updated November 2018