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Diabetic ketoacidosis
NICE guideline [NG18]Published: 01 August 2015 Last updated: 29 June 2022
Measure capillary blood glucose at presentation in children and young people without known diabetes who have:
increased thirst, polyuria, recent unexplained weight loss or excessive tiredness and any of
nausea, vomiting, abdominal pain, hyperventilation, dehydration or reduced level of consciousness.
Be aware that children and young people taking insulin for diabetes may develop DKA with normal blood glucose levels.
Suspect DKA even if the blood glucose is normal in a child or young person with known diabetes and any of the following:
nausea or vomiting
abdominal pain
hyperventilation
dehydration
reduced level of consciousness.
When a child or young person with suspected or known DKA arrives at hospital, measure their:
capillary blood glucose
capillary blood ketones (beta‑hydroxybutyrate) if near‑patient testing is available, or urine ketones if it is not
capillary or venous pH and bicarbonate.
Diagnose DKA in children and young people with diabetes who have:
hyperglycaemia (plasma glucose more than 11 mmol/litre) and
acidosis (indicated by blood pH below 7.3 or plasma bicarbonate below 15 mmol/litre) and
ketonaemia (indicated by blood beta‑hydroxybutyrate above 3 mmol/litre) or ketonuria (++ and above on the standard strip marking scale).
Diagnose DKA severity as follows:
mild DKA if blood pH is below 7.3 or plasma bicarbonate is below 15 mmol/litre
moderate DKA if blood pH is below 7.2 or plasma bicarbonate is below 10 mmol/litre
severe DKA if blood pH is below 7.1 or plasma bicarbonate is below 5 mmol/litre.
Inform the responsible senior clinician when a child or young person is diagnosed with DKA.
When DKA is diagnosed in a child or young person in hospital, record their:
level of consciousness
heart rate, blood pressure, temperature, respiratory rate (look for Kussmaul breathing)
history of nausea or vomiting
clinical evidence of dehydration
body weight.
When DKA is diagnosed in a child or young person in hospital, measure and record the capillary or venous:
pH and pCO2
plasma sodium, potassium, urea and creatinine
plasma bicarbonate. [2015]
Consider a near‑patient blood ketone (beta‑hydroxybutyrate) testing method for rapid diagnosis and monitoring of DKA in children and young people in hospital.
Think about inserting a nasogastric tube if a child or young person with DKA has a reduced level of consciousness and is vomiting.
Seek urgent anaesthetic review and discuss with a paediatric critical care specialist if a child or young person with DKA cannot protect their airway because they have a reduced level of consciousness.
Discuss the use of inotropes with a paediatric critical care specialist if a child or young person with DKA is in hypotensive shock.
Think about sepsis in a child or young person with DKA who has any of the following:
fever or hypothermia
hypotension
refractory acidosis
lactic acidosis.
Treat DKA with intravenous fluids and intravenous insulin if the child or young person is not alert, is nauseated or vomiting, or is clinically dehydrated.
Do not give oral fluids to a child or young person who is receiving intravenous fluids for DKA unless ketosis is resolving, they are alert, and they are not nauseated or vomiting.
For children and young people with DKA who are clinically dehydrated but not in shock:
give an initial intravenous bolus of 10 ml/kg 0.9% sodium chloride over 30 minutes
discuss with the responsible senior paediatrician before giving more than one intravenous bolus of 10 ml/kg 0.9% sodium chloride
only consider giving a second 10 ml/kg 0.9% sodium chloride intravenous bolus if needed to improve tissue perfusion, and only after reassessing their clinical status
when calculating the total fluid requirement, subtract these initial bolus volumes from the total fluid deficit.
For children and young people who have signs of shock, that is weak, thready (low-volume) pulse and hypotension, give an initial intravenous bolus of 20 ml/kg 0.9% sodium chloride as soon as possible. When calculating the total fluid requirement, do not subtract this fluid bolus from the total fluid deficit.
Be aware that:
shock is rare in children and young people with DKA
prolonged capillary refill, tachycardia and tachypnoea are common in children with moderate to severe DKA, but this does not mean the child or young person is in shock (these are signs of vasoconstriction caused by metabolic acidosis and hypocapnia).
Calculate the total fluid requirement for the first 48 hours in children and young people with DKA by adding the estimated fluid deficit to the fluid maintenance requirement:
For the fluid deficit:
in mild to moderate DKA (blood pH 7.1 or above), assume 5% dehydration (so a 10 kg child needs 500 ml)
in severe DKA (blood pH below 7.1), assume 10% dehydration
aim to replace the deficit evenly over the first 48 hours, but in critically ill children and young people, discuss the fluid regimen early with the senior paediatrician or paediatric intensivist (or both), because the risk of cerebral oedema is higher.
For the fluid maintenance requirement, use the Holliday-Segar formula:
give 100 ml/kg for the first 10 kg of weight
give 50 ml/kg for the second 10 kg of weight
give 20 ml/kg for every kg after this
use a maximum weight of 75 kg in the calculation.
When calculating the total fluid requirement, subtract any initial bolus volumes from the total fluid deficit (unless the child or young person is in shock). [2020]
Use 0.9% sodium chloride without added glucose for both rehydration and maintenance fluid in children and young people with DKA, until the plasma glucose concentration is below 14 mmol/litre.
Be aware that some children and young people with DKA may develop hyperchloremic acidosis, but this resolves on its own over time and specific management is not needed.
Include 40 mmol/litre (or 20 mmol/500 ml) potassium chloride in all fluids (except the initial intravenous boluses) given to children and young people with DKA, unless they have anuria or their potassium level is above the normal range. Do not delay potassium replacement, because hypokalaemia can occur once the insulin infusion starts.
For children and young people with potassium levels above the normal range, only add 40 mmol/litre (or 20 mmol/500 ml) potassium chloride to their intravenous fluids if:
their potassium is less than 5.5 mmol/litre or
they have a history of passing urine.
For children and young people with DKA who have hypokalaemia at presentation, include potassium chloride in intravenous fluids before starting the insulin infusion.
Monitor sodium levels throughout DKA treatment, and calculate the corrected sodium initially to identify if the child or young person has hyponatraemia.
When monitoring serum sodium levels in children and young people with DKA, be aware that:
serum sodium should rise as DKA is treated as blood glucose falls
falling serum sodium is a sign of possible cerebral oedema
a rapid and ongoing rise in serum sodium concentration may also be a sign of cerebral oedema, caused by the loss of free water in the urine.
Do not give intravenous sodium bicarbonate to children and young people with DKA unless:
they have compromised cardiac contractility, caused by life-threatening hyperkalaemia or severe acidosis and
you have discussed with the paediatric intensivist.
Do not give children and young people with DKA additional intravenous fluid to replace urinary losses.
Start an intravenous insulin infusion 1 to 2 hours after beginning intravenous fluid therapy in children and young people with DKA. If a child or young person with DKA is using an insulin pump, disconnect the pump when starting intravenous insulin therapy.
When treating DKA with intravenous insulin in children and young people, use a soluble insulin infusion at a dosage between 0.05 and 0.1 units/kg/hour. Do not give bolus doses of intravenous insulin.
In discussion with a diabetes specialist, think about continuing subcutaneous basal insulin in a child or young person who was using a basal insulin before DKA started.
When the plasma glucose concentration falls below 14 mmol/litre in children and young people with DKA, change fluids to 0.9% sodium chloride with 5% glucose and 40 mmol/litre (or 20 mmol/500 ml) potassium chloride.
If a child or young person’s plasma glucose falls below 6 mmol/litre during DKA treatment:
increase the glucose concentration of the intravenous fluid infusion and
if they have persisting ketosis, continue to give insulin at a dosage of least 0.05 units/kg/hour.
If the blood beta‑hydroxybutyrate level is not falling within 6 to 8 hours in a child or young person with DKA, think about increasing the insulin dosage to 0.1 units/kg/hour or more.
Think about stopping intravenous fluid therapy for DKA in a child or young person if:
ketosis is resolving and their blood pH has reached 7.3 and
they are alert and
they can take oral fluids without nausea or vomiting.
Discuss with the responsible senior paediatrician before stopping intravenous fluid therapy and changing to oral fluids for DKA in a child or young person if they still have mild acidosis or ketosis.
Do not change from intravenous insulin to subcutaneous insulin in a child or young person with DKA until ketosis is resolving, they are alert, and they can take oral fluids without nausea or vomiting.
Start subcutaneous insulin in a child or young person with DKA at least 30 minutes before stopping intravenous insulin.
For a child or young person with DKA who is using an insulin pump, restart the pump at least 60 minutes before stopping intravenous insulin. Change the insulin cartridge and infusion set, and insert the cannula into a new subcutaneous site.
Monitor and record the following at least hourly in children and young people with DKA:
capillary blood glucose
heart rate, blood pressure, temperature, respiratory rate (look for Kussmaul breathing)
fluid balance, with fluid input and output charts
level of consciousness (using the modified Glasgow coma scale).
Monitor and record the level of consciousness (using the modified Glasgow coma scale) and heart rate (to detect bradycardia) every 30 minutes in:
children under 2 years with DKA
children and young people with severe DKA (blood pH below 7.1).
This is because these children and young people are at increased risk of cerebral oedema.
Monitor children and young people having intravenous therapy for DKA using continuous electrocardiogram (ECG), to detect signs of hypokalaemia (including ST‑segment depression and prominent U‑waves).
At 2 hours after starting treatment, and then at least every 4 hours, carry out and record the results of the following blood tests in children and young people with DKA:
glucose (laboratory measurement)
blood pH and pCO2
plasma sodium, potassium and urea
beta‑hydroxybutyrate.
A doctor involved in the care of the child or young person with DKA should review them face‑to‑face at diagnosis and then at least every 4 hours, and more frequently if:
they are aged under 2 years
they have severe DKA (blood pH below 7.1)
there are any other reasons for special concern.
At each face‑to‑face review of children and young people with DKA, assess the following:
clinical status, including vital signs and neurological status
results of blood investigations
ECG trace
cumulative fluid balance record.
Immediately assess children and young people with DKA for suspected cerebral oedema if they have any of these early manifestations:
headache
agitation or irritability
unexpected fall in heart rate
increased blood pressure.
If cerebral oedema is suspected in a child or young person with DKA, start treatment immediately.
Start treatment for cerebral oedema immediately in children and young people with DKA and any of these signs:
deterioration in level of consciousness
abnormalities of breathing pattern, for example respiratory pauses
oculomotor palsies
pupillary inequality or dilatation.
When treating cerebral oedema in children and young people with DKA, use the most readily available of:
mannitol (20%, 0.5 to 1 g/kg over 10 to 15 minutes) or
hypertonic sodium chloride (2.7% or 3%, 2.5 to 5 ml/kg over 10 to 15 minutes).
After starting treatment for cerebral oedema with mannitol or hypertonic sodium chloride in a child or young person with DKA, immediately seek specialist advice on further management, including which care setting would be best.
If a child or young person with DKA develops hypokalaemia (potassium below 3 mmol/litre):
think about temporarily suspending the insulin infusion
discuss hypokalaemia management urgently with a paediatric critical care specialist, because a central venous catheter is needed to give intravenous potassium solutions above 40 mmol/litre.
Be aware of the increased risk of venous thromboembolism in children and young people with DKA, especially if they have a central venous catheter.