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(Add MedicationDose templates for insulin and sodium bicarbonate in pediatric DKA)
 
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{{PediatricPage|diabetic ketoacidosis}}
==Background==
==Background==
*(pH <7.25-7.30 or bicarb <15) + hyperglycemia (>300) + ketonemia (>1:2 serum dilution)
*DKA + altered mental status = [[Cerebral edema in DKA|cerebral edema]] until proven otherwise
*DKA + AMS = cerebral edema until proven otherwise
 
==Clinical Features==
[[File:PMC3937174 2251-6581-12-47-1.png|thumb|Frequency of signs and symptoms among 37 pediatric patients with diabetic ketoacidosis in Nigeria.]]
*May be the initial presenting of an unrecognized Type-1 diabetes mellitus patient
*Signs/symptoms may include:
**[[Tachypnea]], Kussmaul's breathing
**[[Polyuria]], polydipsia, polyphagia, [[failure to thrive (peds)|poor weight gain]]/weight loss
**Signs of [[dehydration (peds)|dehydration]]
**[[Abdominal pain]], [[nausea and vomiting (peds)|nausea/vomiting]]
**[[Altered mental status (peds)|Altered mental status]], drowsiness, lethargy
**Breath fruity odor (acetone)
***Perform a thorough neurologic exam as cerebral edema increases mortality significantly, especially in children
*+/- signs/symptoms of precipitating trigger for decompensation (e.g. [[pneumonia]], [[cellulitis]])
*Keep in mind that the initial presentation of sepsis with dehydration can look very similar to DKA
 
==Differential Diagnosis==
{{Hyperglycemia DDX}}
 
==Evaluation==
===Workup===
*Point of care glucose (and potassium, if available)
*[[VBG]]
*Chem 7
*Magnesium
*Phosphorus
*Serum ketones (or beta-OH and acetone)
*[[Urinalysis]]
*CBC
*Urine pregnancy (if appropriate)
*Consider infectious workup to identify trigger


==Cerebral Edema==
===Risk Factors===
#Age <5yo
##Rare in >20yo
#Severe hyperosmolality
#Failure of Na to rise w/ therapy
#Severe acidosis
#Overaggressive fluid resus is NOT a risk factor
===Diagnosis===
===Diagnosis===
*Begins 6-12hr after onset of therapy
*[[Hyperglycemia]] (>200)
*Many appear to be improving from their DKA before deteriorating from cerebral edema
*[[Acidosis]]
*Premonitory symptoms:
**pH <=7.30 or bicarb <=15
**HA, declining mental status, sz, respiratory arrest
*+ketonemia (>1:2 serum dilution)
===Treatment===
*Mannitol 0.5-1gm/kg IV bolus OR 3% saline 10mL/kg over 30min
*Fluid restriction


==General Treatment==
==General Treatment==
*IV Fluids
*Initial bolus 20ml/kg NS x 1 (repeat boluses only for shock or poor perfusion)<ref>Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5</ref>
**NS @ 10ml/hr/kg for stable VS
 
**Bolus 20ml/kg NS only for unstable VS
===[[IV Fluids|Manage Hydration]]<ref>Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5</ref>===
**Replace fluid deficit evenly over 48hr w/ NS or 1/2 NS
*If K+<5.5
**When BS <250:
**0.45% NS (or NS) + 20 KPhosat 1.5 x [[IVF maintenance|maintenance rate]]
***Change fluid to D51/2NS @ rate to correct fluid deficit in 48hr; maintain BS 150-250
***When BS <300, change to D5/0.45%NS (or NS) +20 KPhos at 1.5 x [[IVF maintenance|maintenance rate]] (maintain BS 150-250)
*Insulin
*In a retrospective study, lactated ringers when compared with normal saline was associated with lower total cost and rate of development of cerebral edema.<ref>Bergmann, K. R., Jennifer Abuzzahab, M., Nowak, J., Arms, J., Cutler, G., Christensen, E., … Kharbanda, A. (2018). Resuscitation With Ringerʼs Lactate Compared With Normal Saline for Pediatric Diabetic Ketoacidosis. Pediatric Emergency Care, 1.</ref>
**IV Infusion 0.1 units/kg/hr
 
***Cont until HCO3 > 15 and pH>7.3
===Manage [[Acidosis]]<ref>Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5</ref>===
**Decrease infusion to 0.05 u/kg/hr until 1hr after SC insulin initiated
*{{MedicationDose|drug=Insulin|dose=0.1 units/kg/hr IV drip|route=IV drip|context=DKA management|indication=Diabetic ketoacidosis (peds)|population=Pediatric|notes=Do not start if K+ <4.0; decrease to 0.05 units/kg/hr when transitioning to SC}}
*Potassium
**Do not start if K+ <4.0 (replete K+ first)
**if < 2.5, hold insulin and give 1 meq/kg KCL in IV over 1hr
**Continue until HCO3 >15 and pH >7.3, then transition to SC insulin
***No insulin until K > 2.5
***Decrease infusion to 0.05 units/kg/hr until 1hr ''after'' SC insulin initiated
**if > 2.5 but < 3.5 give 40-60 meq/L in IV until K > 3.5
 
**if > 3.5 but < 5.5 give 30-40 meq/L in IV for K=3.5 - 5
===Potassium===
**if > 5.5, then check K q1hr
*if <2.5, hold insulin and give 1 meq/kg potassium KCL in IV over 1hr
*Bicarbonate
**No insulin until K >2.5
**Only consider for:
*if >2.5 but <3.5 give 40-60 meq/L in IV until K >3.5
***Critically ill (hemodynamic compromise from decr contractility) AND
*if >3.5 but <5.5 give 30-40 meq/L in IV for K = 3.5 - 5
***pH <7.0
*if >5.5, then check K q1hr
**0.5-2 mEq/kg over 1-2hr
 
===[[Bicarbonate]]<ref>[[EBQ:Sodium Bicarbonate use in DKA]]</ref>===
{{EBQ Sodium Bicarbonate use in DKA conclusion}}
*Only consider for:
**Critically ill (hemodynamic compromise from decreased contractility) AND
**pH <7.0
*{{MedicationDose|drug=Sodium bicarbonate|dose=0.5-2 mEq/kg over 1-2 hr|route=IV|context=Only if pH <7.0 and hemodynamic compromise|indication=Diabetic ketoacidosis (peds)|population=Pediatric|notes=Correction should never exceed pH >7.1 or bicarb >10}}
**Correction should never exceed pH > 7.1 or bicarb >10
**Correction should never exceed pH > 7.1 or bicarb >10


==Disposion==
===Monitor for Complications<ref>Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5</ref>===
*Admit all except can consider dischage if:
*[[Cerebral edema in DKA|Cerebral edema]] (1% of DKA)
**Acute [[altered mental status (peds)|change in mental status]]
**Signs of [[herniation Syndromes|herniation]]
*If present, see [[Cerebral Edema in DKA]]
 
==Disposition==
*Admit all (usually to PICU, if on insulin drip) unless
**Known diabetes
**Known diabetes
**pH > 7.35 and bicarb > 20
**pH >7.35 and bicarb >20
**Known and resolving precipitant for DKA
**Known and resolving precipitant for DKA


==Source==
==Complications==
Tintinalli
*[[Cerebral Edema in DKA]]
 
==See Also==
*[[Diabetes mellitus (main)]]
*[[Diabetic ketoacidosis]] (main)
*[[EBQ:Sodium Bicarbonate use in DKA]]
*[[Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis]]
 
==External Links==
*[http://pemplaybook.org/podcast/vomiting-in-the-young-child-nothing-or-nightmare/ Pediatric Emergency Playbook -- Vomiting in the Young Child: Nothing or Nightmare]
 
==References==
<references/>


[[Category:Peds]]
[[Category:Pediatrics]]
[[Category:Endo]]
[[Category:Endocrinology]]

Revisión actual - 22:23 20 mar 2026

This page is for pediatric patients. For adult patients, see: diabetic ketoacidosis

Background

Clinical Features

Frequency of signs and symptoms among 37 pediatric patients with diabetic ketoacidosis in Nigeria.
  • May be the initial presenting of an unrecognized Type-1 diabetes mellitus patient
  • Signs/symptoms may include:
  • +/- signs/symptoms of precipitating trigger for decompensation (e.g. pneumonia, cellulitis)
  • Keep in mind that the initial presentation of sepsis with dehydration can look very similar to DKA

Differential Diagnosis

Hyperglycemia

Diabetic Emergencies

Diabetes Mellitus (New or Known)

Medication/Drug-Induced

Physiologic Stress Response

  • Sepsis / critical illness (stress hyperglycemia — very common in the ED)
  • Trauma / major surgery / burns
  • Acute coronary syndrome / myocardial infarction
  • Stroke (especially hemorrhagic)
  • Pancreatitis (both a cause and consequence)
  • Shock (any etiology)
  • Pain (catecholamine surge)
  • Seizure (postictal)
  • Physiologic stress alone rarely causes glucose >200 mg/dL in non-diabetics; glucose >200 in a "stress response" should prompt evaluation for undiagnosed diabetes or prediabetes

Endocrine

Pancreatic

  • Pancreatitis (acute or chronic — destruction of islet cells)
  • Pancreatic malignancy (adenocarcinoma, neuroendocrine tumors)
  • Post-pancreatectomy
  • Cystic fibrosis-related diabetes
  • Hemochromatosis (iron deposition in pancreas — "bronze diabetes")

Toxic/Overdose

Other

  • Renal failure (chronic kidney disease, acute kidney injury — impaired insulin clearance AND insulin resistance)
  • Cirrhosis / hepatic failure (impaired glycogenolysis regulation)
  • Pregnancy (gestational diabetes, steroid administration for fetal lung maturity)
  • Parenteral nutrition (TPN, dextrose-containing fluids)
  • Post-transplant diabetes (immunosuppressants)

Complications of Diabetes (Not Causes of Hyperglycemia)

These are associated conditions that may be present alongside hyperglycemia but do not themselves cause elevated glucose:

Evaluation

Workup

  • Point of care glucose (and potassium, if available)
  • VBG
  • Chem 7
  • Magnesium
  • Phosphorus
  • Serum ketones (or beta-OH and acetone)
  • Urinalysis
  • CBC
  • Urine pregnancy (if appropriate)
  • Consider infectious workup to identify trigger

Diagnosis

General Treatment

  • Initial bolus 20ml/kg NS x 1 (repeat boluses only for shock or poor perfusion)[1]

Manage Hydration[2]

  • If K+<5.5
  • In a retrospective study, lactated ringers when compared with normal saline was associated with lower total cost and rate of development of cerebral edema.[3]

Manage Acidosis[4]

  • Insulin 0.1 units/kg/hr IV drip IV drip — Do not start if K+ <4.0; decrease to 0.05 units/kg/hr when transitioning to SC
    • Do not start if K+ <4.0 (replete K+ first)
    • Continue until HCO3 >15 and pH >7.3, then transition to SC insulin
      • Decrease infusion to 0.05 units/kg/hr until 1hr after SC insulin initiated

Potassium

  • if <2.5, hold insulin and give 1 meq/kg potassium KCL in IV over 1hr
    • No insulin until K >2.5
  • if >2.5 but <3.5 give 40-60 meq/L in IV until K >3.5
  • if >3.5 but <5.5 give 30-40 meq/L in IV for K = 3.5 - 5
  • if >5.5, then check K q1hr

Bicarbonate[5]

  • No evidence supports the use of sodium bicarb in DKA, with a pH >6.9
  • However, no studies have been performed for patients with pH <6.9 and the most recent ADA guidelines recommend it for patients with pH <7.1
  • Only consider for:
    • Critically ill (hemodynamic compromise from decreased contractility) AND
    • pH <7.0
  • Sodium bicarbonate 0.5-2 mEq/kg over 1-2 hr IV — Correction should never exceed pH >7.1 or bicarb >10
    • Correction should never exceed pH > 7.1 or bicarb >10

Monitor for Complications[6]

Disposition

  • Admit all (usually to PICU, if on insulin drip) unless
    • Known diabetes
    • pH >7.35 and bicarb >20
    • Known and resolving precipitant for DKA

Complications

See Also

External Links

References

  1. ↑ Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5
  2. ↑ Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5
  3. ↑ Bergmann, K. R., Jennifer Abuzzahab, M., Nowak, J., Arms, J., Cutler, G., Christensen, E., … Kharbanda, A. (2018). Resuscitation With Ringerʼs Lactate Compared With Normal Saline for Pediatric Diabetic Ketoacidosis. Pediatric Emergency Care, 1.
  4. ↑ Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5
  5. ↑ EBQ:Sodium Bicarbonate use in DKA
  6. ↑ Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5
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