Acute Management of Pediatric DKA

A quick-reference educational tool for providers


  • This educational tool on pediatric diabetic ketoacidosis contains a module, which consists of a case scenario and 3 questions; and recommendations for the treatment of pediatric DKA.
  • This tool was based on the 2006 American Diabetes Association guidelines for management of pediatric DKA.


Janine Zee-Cheng, MD
Alexander Djuricich, MD
Emily Webber, MD
Samer Abu-Sultaneh, MD

Interactive Module

Case Presentation

  • An 8-year-old female presents with increased thirst, increased urination, and weight loss over 1 week.
  • On exam, her heart rate is 153, respiratory rate 34 breaths per minute, oxygen saturation 99% on room air, capillary refill 3 seconds, blood pressure 90/44, weight 32 kg.
  • She is awake and alert, complaining only of mild abdominal pain.


  • For the patient with no respiratory distress and stable hemodynamics, and a history concerning for diabetic ketoacidosis, the appropriate next step would be to assess blood glucose and electrolytes.
  • Weight from prior encounters should not be used.

Initial Labs

  • A venous blood gas with point-of-care electrolytes is obtained.
    • pH 7.09
    • pC02 30
    • pO2 50
    • Bicarb 7
    • Blood glucose 415 mg/kL
    • Sodium 142
    • Potassium 4.4


  • Initial fluid resuscitation should be performed with isotonic fluid such as normal (0.9%) saline or Lactated Ringer’s.
  • Volume depends on circulatory status but is typically 10-20mL/kg over 1-2 hours and may be repeated.
  • Hourly blood glucose checks are recommended
  • Insulin bolus is not recommended as it may increase risk of cerebral edema.
  • Sodium bicarbonate is not recommended.

Labs after 2 hours (following fluid resuscitation)

  • A venous blood gas with point-of-care electrolytes is obtained.
    • pH 7.19
    • pC02 34
    • pO2 53
    • Bicarb 10
    • Blood glucose 265 mg/dL
    • Sodium 141
    • Potassium 4.1


  • To prevent an unduly rapid decrease in plasma glucose concentration and osmolality and prevent hypoglycemia, 5% glucose should be added to the intravenous fluid when plasma glucose falls to 300 mg/dL (10% or 12.5% glucose may be necessary).
    • Osmolality=2 (Na+K) + (Glucose/18) + (BUN/2.8)
  • After initial fluid resuscitation, fluid management should be with isotonic fluid for at least 4-6 hours.
  • Start insulin infusion after the patient has received initial volume expansion; ie, 1-2 h after starting fluid replacement therapy.



  • Initial and hourly
    • Respiratory effort (may need supplemental oxygen, additional respiratory support, maintenance of airway if very obtunded
    • Capillary refill and pulses (assess for shock)
    • Mental status
  • Once
    • Weight from current encounter


  • Initial resuscitation (fluid bolus)
    • Use isotonic fluid (Normal saline, Lactated Ringer’s)
    • 10-20mL/kg over 1-2 hours; this may be repeated
    • Do not exceed 40mL/kg over less than 2 hours
      • Overly vigorous fluid resuscitation may be associated with increased risk of cerebral edema (Bohn 2002)
      • Deviation from recommendations should be performed only with assistance from a physician expert.
  • After initial resuscitation
    • Isotonic fluids with potassium
    • Run concurrently with insulin
      • 1.5 to 2 times maintenance rate
    • If blood sugar falls below 300, add 5% dextrose to fluids
    • It may be necessary to use 10% or 12.5% dextrose fluids if glucose continues to fall

Blood glucose

  • Blood glucose monitoring should be performed hourly!
    • This is to monitor for overly rapid drop in blood glucose and osmolality
    • Osmolality=2 (Na+K) + (Glucose/18) + (BUN/2.8)


  • Bolus insulin (subcutaneous/IV) is not recommended
    • Bolus insulin has been shown to be unnecessary in pediatric patients and may increase the risk of cerebral edema (Lindsay 1989, Edge 2005)
  • Insulin infusion at 0.1 unit/kg/hr after initial fluid resuscitation has been completed (may be started after at least 1-2 hours)
  • Smaller dose of insulin (0.05 unit/kg/hr) may be used in smaller children


  • Hourly
    • Serum or plasma glucose
      • If checking capillary glucose, must be crosschecked against laboratory value, as may be affected by poor circulation and acidosis
  • Every 2-4 hours
    • Electrolytes (including bicarbonate)
    • Venous blood gas (arterial not necessary unless critically ill)
    • Calcium, phosphorus, magnesium concentrations
  • Every 6-8 hours
    • Blood urea nitrogen, creatinine, hematocrit
  • Until cleared
    • Urine ketones
  • Once
    • Hemoglobin A1C, blood hydroxybutyrate concentration

Sodium bicarb

  • Sodium bicarbonate is not recommended in pediatric DKA!
    • Evidence does not justify the administration due to possible clinical harm and lack of sustained benefits (Chua 2011)


  • Wolfsdorf J, Glaser N, Sperling MA. Diabetic ketoacidosis in infants, children, and adolescents: a consensus statement from the American Diabetes Association. Diabetes Care. 2006. 29(5)1150-1159.
  • Bohn D, Daneman D. Diabetic ketoacidosis and cerebral edema. Curr Opin Pediatr. 2002. 14:287-289.
  • Lindsay R, Bolte RG. The use of an insulin bolus in low-dose insulin infusion for pediatric diabetic ketoacidosis. Pedaitr Emerg Care. 1989. 5:77-79.
  • Edge J, Jakes R, et al. The UK prospective study of cerebral oedema complicating diabetic ketoacidosis. Arc Dis Child. 2005. 90(Suppl 11):A2-A3.
  • Chua HR, Schneider A, Bellomo R. Bicarbonate in diabetic ketoacidosis—a systematic review. Ann Int Care. 2011; 1:23.