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Pediatric Diabetic Ketoacidosis (DKA) Algorithm (Page 1-ED)

Alert and oriented patients ONLY Patient presents to the ED with suspected DKA Do NOT administer insulin bolus.
If any mental status concerns, suspect cerebral
edema and intervene immediately
Do NOT administer bicarb.
Initial Labs: Glucose POC, Potassium, whole blood; Sodium, whole blood; BMP (sodium, potassium, chloride, total carbon
dioxide, anion gap, glucose, BUN, creatinine, calcium); pH; Magnesium; Phosphate; Urinalysis; Consider Hgb A1C if not
completed in the last 90 days. (Refer to order set ED-DKA-Ped [3464]. See section Initial Orders-First Hour.)
Initial Lab
Tests and Evaluation:
Evaluation • Perform hourly neurological exams and vitals, watching for signs of cerebral edema (see box in page 2 of this algorithm,
Complications of DKA)
• Evaluate hydration status
• Perform continuous electrocardiogram monitoring to assess for hyper- or hypokalemia and arrhythmias
• Stop patient’s insulin pump (if applicable)

IV Fluids Is patient
(1st Hour) Normal saline maintenance No Yes Normal saline 20 mL/kg
dehydrated?

DKA Not Diagnosed DKA Diagnosed

Refer to order set ED-DKA-Ped [3464]. See section DKA-Second Hour
Refer to order set ED-DKA-Ped [3464]. See section Not DKA-Second Hour,
Diabetes Sick Day/ Ketones orders
pH < 7.25 and CO2 < 15
Lab Results pH > 7.25 and CO2 > 15 If only one of above parameters is abnormally low, consider
DKA if anion gap > 15 and/or unwell clinical appearance.

1. Consult Pediatric Endocrinology to discuss:

• Last insulin dose (long-acting and short-acting) 1. Consult PICU
• Current lab values
• Correction factor and patient sick day plans 2. Administer IV insulin regular (0.1 units/kg/hr).
(see last clinic visit note) If initial K < 3 mmol/L, replete potassium (IV) while starting insulin.

2. Administer subcutaneous insulin lispro (once) based 3. Administer 2nd Hour IV fluids at 1.5 x maintenance IV fluid rate
on discussion with Pediatric Endocrinology. Consider according to 2-bag system:
insulin glargine if patient reports missed dose of long- • If K > 5.5 mmol/L, 0.9% NS (Bag A) and 0.9% NS with 10% dextrose
acting insulin. Check blood sugar every 2-3 hours and (Bag B) given in ratio dependent upon blood glucose (see table
below)
give correction insulin every 2-3 hours.
• If K < 5.5 mmol/L, 0.9% NS with K and Phos (Bag A) and 0.9% NS
with 10 % dextrose with K and Phos (Bag B) given in ratio
3. Administer further 0.9% NS boluses as needed dependent upon blood glucose (see table below)
depending on degree of dehydration. If unable to take
orally, consider starting 0.9% NS with 5% dextrose at 4. Consider 2nd IV for
maintenance rate with close attention to glycemic hourly lab draws:
control. Glucose, POC; pH;
Electrolytes, whole blood
4. Evaluate disposition. Instruct patient and family to (sodium, potassium,
check blood sugar every 2-3 hours and give correction chloride, total carbon
insulin every 2-3 hours. Consider providing contact dioxide, anion gap)
information for diabetes resources (608-263-6420 or
www.uwhealthkids.org/type1diabetes)

Discharge Admit to General Care

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. Admit to PICU ASAP
2. Kapellen T, Vogel C, Telleis D, Siekmeyer M, Kiess W. Treatment of diabetic ketoacidosis (DKA) with 2 different regimens rega rding 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 Full Guideline: Diabetes – Pediatric/Adult – Inpatient/
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. Ambulatory Guideline
5. American Diabetes Association. Standards of Medical Care in Diabetes-2019. Diabetes Care. 2019;41(Suppl 1): S1-193.

Copyright © 2019 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: Lee Vermeulen, [email protected]
[email protected] Last Revised: 02/2019
 Effective03/06/2019. Contact [email protected] for previous versions
Pediatric Diabetic Ketoacidosis (DKA) Algorithm (Page 2 - PICU)
Patient is admitted to the PICU with DKA
Refer to order set IP - Diabetic Ketoacidosis - Pediatric - Intensive Maintain patient on insulin drip at 0.1 units/kg/hr until
Care - Admission [1196] patient has clinically improved and the following
criteria are met:
Normal neuro status
AND
Begin/continue DKA treatment: Clinically appropriate to eat and drink
1. Administer IV insulin regular infusion and IV fluids according to AND
the 2-bag system. See page 1 of this algorithm. Anion gap normalized, pH > 7.25 and bicarbonate >15*
Total fluid rate is determined by hydration status: AND
-If dehydrated, then 20 mL/kg Phosphate >2.0*
-If not dehydrated, then maintenance rate AND
Potassium > 3.0*
2. Hourly glucose POC, vital signs, I/O, neurologic status (watching *using results from Basic Metabolic Panel: (Do not use
for signs of cerebral edema). whole blood electrolytes / blood gas results to determine
anion gap or bicarbonate; these results are calculated, not
3. Titrate ratio of bag A/B IV fluids hourly based on glucose. measured)
Gradual correction of hyperosmolar state over 36 - 48 hours
without excessive free water is believed to reduce the chance of
cerebral edema.

4. Check whole blood electrolytes every 2 hours. If deficient,

replete electrolytes (most commonly deficient: K, Phos, Mg) When above criteria are met,
transition to subcutaneous insulin and
5. Evaluate continuous telemetry (to watch for dysrhythmias from consider transfer to Pediatric General Care.
electrolyte abnormalities) See order sets Diabetes Management With or Without
Pump - Pediatric – Supplemental
6. Avoid administering bicarbonate: Rarely indicated. May increase
risk of cerebral edema.

7. Obtain HbA1c and if patient is newly diagnosed with diabetes,

KEY POINTS FOR
also obtain TSH, free T4, TTG IgA, IA2 and GAD65 TRANSITION TO SUBCUTANEOUS INSULIN
1. Subcutaneous insulin plan should be reviewed with pediatric
diabetes team prior to transition.
8. Assess ongoing ketotic acidosis with basic metabolic panel with
Mg and Phos every 6 hours (these are true measured electrolytes & 2. If patient uses a pump, a new pump site will need to be placed by
should be used to determine bicarbonate & anion gap). parent before restarting pump.

3. Once ready to transition, give subcutaneous insulin and 30 minutes

later, stop the insulin drip and stop the IV fluids (order sets: Diabetes
Management With or Without Pump - Pediatric – Supplemental). The
short half-life of IV insulin (3-4 minutes) will result in insulinopenia and
COMPLICATIONS OF DKA
hyperglycemia if the IV insulin is discontinued prematurely at the time
1.Cerebral edema: rare but high mortality – occurs in ~7 per 1000 pts in DKA,
of subcutaneous insulin administration.
most commonly during hour 4 to 12 of treatment.
Risk factors1:
4. If patient is still ill from an unrelated cause or at risk for recurrence
• Presentation related - Younger age, new diagnosis of diabetes, severity of
of DKA, consider using “Sick Day/Ketone” orders to provide more
acidosis, high BUN, low bicarb
frequent insulin administration.
• Treatment related - Administration of bicarbonate, large/rapid
rehydration, insulin boluses, decreasing Na with therapy
Warning Signs/Symptoms: Bradycardia (relative), headache, altered mental
status, incontinence, vomiting, lethargy FREQUENTLY USED EQUATIONS
Treatment: Mannitol 0.5-1 g/kg IV over 15 min or 3% Hypertonic Saline 3-6 mL/ 1. Osmolality = 2[Na]+[BUN]/2.8 + [GLUCOSE]/18 (DKA is a
kg over 5-10 min; establish airway and hyperventilate. hyperosmolar state)
2. Cardiac dysrhythmias:
Due to electrolyte abnormalities 2. Corrected Sodium: [Na] + 1.6[(glucose –100)/100] (The correction
Prevention: telemetry during treatment of DKA and be proactive in repleting accounts for the free water that leaves the intracellular space and goes
electrolytes) into the extracellular space to maintain equal osmolality.)
3. Hypoglycemia: all patients on insulin should have orders for dextrose (if IV is
placed), glucose-tabs (oral) and glucagon 3. Potassium: levels rise 0.6 mM for each 0.1 unit ↓ in serum pH
Glucagon: 1mg for older pts > 20kg, 0.5mg for younger pts < 20kg (Potassium is falsely higher due to acidosis - this calculation corrects
Dextrose: 0.5g/kg for low pH)

References: 4. Anion gap = Na – [Cl + HCO3] (normal 12 ± 2) (In DKA, ketones are
1. Watts W, Edge J. How can cerebral edema during treatment of diabetic ketoacidosis be avoided?
Pediatric Diabetes. May 2014;15(4):271-276.
an unmeasured anion that makes the anion gap high)

Full Guideline: Diabetes – Pediatric/Adult – Inpatient/Ambulatory Guideline

Copyright © 2019 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: Lee Vermeulen, [email protected]
[email protected] Last Revised: 02/2019