Paediatric Diabetic Ketoacidosis

Patient Name Date

Diagnosis of DKA

Emergency Management

Monitoring

Blood glucose >11mmol/L and pH<7.3 bicarb <15 mEq/L
Finger prick blood ketone > 3 mmol/L
Use guideline if >5% dehydrated, vomiting, drowsy or clinically acidotic

MAJOR RISK = CEREBRAL OEDEMA
Aim for slow metabolic correction over 48 hrs

1) Airway: if coma, insert airway. NGT if coma or vomiting
2) Breathing:give 100% oxygen by face mask
3) Circulation: Insert IV cannula, take blood samples
4) If shocked, 10ml/kg 0.9% saline bolus, up to 30ml/kg
5) Confirm diagnosis of DKA
6) Investigations: blood glucose, plasma Na, Cl, Ur, Cr

1) Strict fluid balance (input / output)
2) Hourly BP and vital signs
3) Hourly blood glucose
4) Blood ketones (1-2 hrly if available)
5) Acid base, plasma Na, K, Cl (4 hrly)
6) 12 hrly weight
7) HDU /PICU if coma, pH<7.1, <1 yr

Fluid Therapy

Patient Weight (kg):
Degree Dehydration (%):
Total Ressus Volume (ml):

Weight	Fluid Maintenance
0 - 12.9 kg	80 ml/kg/24 hrs
13 -19.9 kg	65 ml/kg/24 hrs
20 -34.9 kg	55 ml/kg/24 hrs
35 -55.9 kg	45 ml/kg/24 hrs
> 60 kg	35 ml/kg/24 hrs

Maintenance rate (ml/kg/day)
Maintenance volume over 48hrs (ml)
Rehydration volume over 48hrs (ml)
Total fluid /48hrs (ml) minus ressus fluid

TOTAL ML PER DAY
TOTAL (ML/KG/DAY)
TOTAL (ML/HOUR)
TOTAL (ML/KG/HR)

(neonates may need 100ml/kg/day) (use 0.9% saline for first 12 hrs)

(includes subtracting ressus fluid given from total fluid requirement over 48 hrs)

Insulin (Only start infusion after 1st hr of resus fluid)

Corrected Na (failure to increase = risk cerebral oedema)

Add 50 units insulin to 50ml solution of 0.9% saline
(concentration 1 unit/ml, 0.1u/kg/hr = 0.1ml/kg/hr)

Required insulin infusion rate (units/kg/hr):

Run Insulin Infusion at: mls/hr

DO NOT REDUCE insulin rate until ketoacidosis improves.
If glucose falls (<14 mmol/L) add Glucose to IVI fluids.

	sample1	sample2
Glucose (mmol/L):
Plasma Na (mmol/L):
Corrected Na:

Corrected Na = Measured Na + 0.3 (Glucose - 5.5) mmol/L

Corrected Na should rise with therapy (0.5-1mmol/hr)

If associated with falling GCS: consider osmotherapy
1) 5ml/kg of 2.7% saline or
2) 0.5-1 gramm/kg mannitol
3) Consider CT head
4) 2.7% saline can be repeated (even if Na is high)

Glucose Calculator

Size of Infusion Bag (ml): % Glucose at Start: % Glucose Needed: