Emergency Department, ICU and Inpatient Clinical Pathway for
Evaluation/Treatment of Children with Suspected Diabetic Ketoacidosis (DKA)

 
60 min
ED Triage
POC glucose, POC beta-hydroxybutyrate (BOHB)
Team Assessment
  • DKA Confirmed
    • Glucose > 200 mg/dL and
    • BOHB > 3 mmol and
    • pH < 7.3 or HCO3 < 15 mmol/L
Ongoing Treatment
  • Care Goals
    • Frequent MS, VS, PE assessment
    • Initial NS bolus over 1st hr
    • Insulin to start after 1st NS bolus
    • Decrease blood glucose (BG)
      • 50-100 mg/dL/hr
    • Adjust dextrose
      • Based on hourly BG
    • Adjust K+
      • Based on q2hr BMP/mag/phos
      • ECG for < 2.5 or K > 6
IVF Rehydration, Electrolytes, Glucose
  • Additional NS or LR bolus as indicated by PE, VS
  • Start NS 1.5x maintenance until electrolyte results
  • Then start 2 bag (D10NS, NS) system:
    • Dextrose provided based on BG
    • Electrolyte content based on K+ level
    • Rate 1.5x maintenance
Glucose Concentration in IVF
Blood Glucose Dextrose
< 200 All D10
200-299 Half D10, half NS
> 300 All NS
Concentration of Potassium in IVF: KCL + KPhos
Serum K KCL KPhos
< 4 30 mEq 30 mEq, 20.4 mM
4-5.4 20 mEq 20 mEq, 13.6 mM
5.5-6 10 mEq 10 mEq, 6.8 mM
> 6 None None
Electrolyte Abnormalities in DKA
Na HCO3 is not recommended
Insulin
  • Start regular insulin 0.1 units/kg/hr after initial NS bolus completed
  • Stop home insulin pump
  • Review Lantus dosing with Endocrine
Labs Monitoring
  • POC BG hourly
  • BMP/mag/phos and POC BOHB q2hr
  • VBG q2hr until pH > 7.0
Physical Monitoring
  • Full Cardiorespiratory Monitoring
  • VS, neuro assessment hourly
Admission Considerations
  • Resolution of DKA
    • MS, VS improved, tolerating sips
    • HCO3 > 15 mmol/L or < 15, BOHB < 2mmol/L
    • Anion gap < 10
Posted: June 2006
Revised: May 2024
Editors: Clinical Pathways Team