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Diabetic Ketoacidosis Management in ChildrenAka: Pediatric DKA Treatment
- See Also
- Management: Phase 1 in Children (Emergent)
- Stabilize shock and Coma states first!
- Correct Volume Deficit
- Initial
- Give 20 cc/kg NS bolus over first 45 minutes
- Repeat fluid bolus until shock corrected
- Next
- Protocol 1 (standard protocol)
- See Pediatric Dehydration Management
- Replace first 50% volume deficit in first 8 hours
- Replace remaining 50% deficit over next 16 hours
- Protocol 2
- NS at 10 cc/kg/hr (+/- 5 cc/kg/hr)
- Until Serum Glucose <250 mg/dl
- Then D5 1/2NS with 20 kcl
- Use 1 to 1.5 x maintenance rate
- NS at 10 cc/kg/hr (+/- 5 cc/kg/hr)
- Protocol 3 (new protocol)
- Protocol uses 0.675% saline
- Administer 2.5 x maintenance rate
- Continue for 24 hours or until no acidosis
- Then administer 1 to 1.5 x maintenance rate
- Efficacy in children (compared with Protocol 1)
- Reduces fluid rate
- May decrease risk of cerebral edema
- Resulted in cost savings >$1000/patient
- Faster acidosis resolution
- Felner (2001) Pediatrics 108:735
- Reduces fluid rate
- Protocol 1 (standard protocol)
- Initial
- Precautions
- Do not drop Serum Osmolality (calc) >3 mOsms/hour
- Risk of cerebral edema
- Slow replacement if Fluid Overload risk
- Follow Intake and output closely
- Do not drop Serum Osmolality (calc) >3 mOsms/hour
- Management: Phase 2 - Acidosis, electrolytes in children
- Potassium Replacement
- Precautions
- Hypokalemia must be corrected prior to Insulin
- Hold Insulin until potassium >2.5 meq/L in children
- Prerequisites
- Electrocardiogram without signs of Hyperkalemia
- Adequate urine output
- Administration: Children
- Serum Potassium <2.5 meq/L
- Do not administer Insulin until potassium >2.5
- KCl 1 meq/kg (to 40 meq) IV over 1 hour, recheck
- This is maximum IV potassium rate!
- Requires cardiac monitoring
- Requires hourly recheck of Serum Potassium
- Serum Potassium 2.5 to 3.5 meq/L
- Give 40-60 meq/L in IV solution
- Recheck Serum Potassium hourly
- Continue replacement until potassium >3.5 meq/L
- Serum Potassium 3.5 to 5.0 meq/L
- Replace 30-40 meq per liter
- Serum Potassium >5.0 meq/L
- Do not administer any potassium
- Monitor every 1 hour until <5.0
- Serum Potassium <2.5 meq/L
- Precautions
- Phosphate Replacement
- Indications
- Serum Phosphorus < 0.5-1.0 mg/dl (Severe Depletion)
- Controversial - May not be required
- Consider if cardiopulmonary adverse affects
- Contraindications
- Renal Insufficiency
- Administration
- Determine Potassium Replacement as above
- Replace part of potassium with potassium phosphate
- Potassium Phosphate: Replace one third potassium
- Potassium Chloride: Replace two thirds potassium
- Indications
- Magnesium Replacement
- Indications
- Symptomatic Hypomagnesemia (Magnesium <1 meq/L)
- Administration
- MgSO4 50%: 0.2 ml/kg/day IM divide in 3 doses
- Indications
- Sodium Bicarbonate Replacement
- Indications
- ABG pH < 7.0 after initial hour of hydration
- Other contributing factors
- Shock or Coma
- Severe Hyperkalemia
- Administration
- Indications
- Potassium Replacement
- Management: Phase 3 - Glucose control in children
- Initial Insulin Dosing
- IV Insulin Drip starting at 0.1 unit/kg/hour
- Maintenance
- Continue Insulin Infusion until acidosis resolves
- When pH>7.3 and serum bicarbonate >15
- Decrease Insulin Infusion to 0.05 units/kg/hour
- Continue Insulin Infusion until SC Insulin started
- Glucose and electolyte monitoring
- Check bedside glucose every 1/2-2 hours until stable
- Recheck chem8 q2-4 hours until stable
- Initiate SC dosing
- Initial Insulin Dosing
- References
