Table 1.
General characteristics of DKA management in the participating PICU
| 1. Fluid management |
| Fluid loading is not required in mild to moderately dehydrated patients. In severely dehydrated patients, use normal saline in bolus (10 ml/kg). If in shock, the deficit may recur. One-time loading should not exceed 500 ml. |
| Calculation of the total fluid intake according to the dehydration of the patients: |
| Total fluid: deficit+maintenance |
| Calculation of the amount of the deficit: |
| 30–50 ml/kg in case of mild dehydration |
| 60–90 ml/kg in case of moderate dehydration |
| 100 ml/kg in case of severe dehydration |
| Hourly fluid volume=(deficit/48)+hourly maintenance |
| (If he is not in shock, the first loaded fluid is subtracted from the total fluid when calculating the hourly fluid amount.) |
| 2. Glycemic control |
| Insulin therapy: |
| Standard insulin after normal saline hydration |
| Insulin infusion is started with a different intravenous access 0.1 UI/kg/hr. Insulin liquid prepared by adding 50 units of regular insulin into 50 ml of saline 0.05–0.1 UI/kg/hr given speed. A dose of 0.05 UI /kg/hr may be preferred in children under the age of three. |
| Target: decrease glycemia 75 mg/dl/hr, if glycemia comes down lower than 50 mg/dl/hr or there is not pH correction in 2–4 hours, insulin infusion rate can be increased to 0.15 U/kg/hr. |
| Glucose administration: |
| Start continuous glucose infusion after reaching <250 mg/dl initiate with 5% glucose and raise glucose infusion concentration |
| If the patient experiences a rapid fall in blood glucose, increase the glucose concentration, do not reduce or discontinue the insulin infusion until the acidosis is corrected. |
| 3. Electrolytes management |
| Na target: 135–150 mEq/L |
| K target 3.5–5 mEq/L |
| PO4 target >3 mEq/L |
| Unless there is renal insufficiency, 40 mmol/L KCL is added to all fluids except bolus fluid. |
| (or half KC+KPO4). If the patient is hyperkalemia, potassium replacement until urine output should be delayed. |
| 4. Laboratory |
| Immediate assessment: |
| Blood glucose-blood and urine ketones-blood gases-serum electrolytes (sodium, potassium, chloride, calcium, phosphate, magnesium)-blood ureic nitrogen and creatinine |
| Hourly: blood glucose |
| Every 2 hourly: blood gases |
| Every 4 hourly: blood ketones, calcium, magnesium-ketones and glucose in urine-blood ureic nitrogen and creatinine. |
| (The frequency of monitoring the parameters can be changed according to the severity of the DKA. If pH >7.3, discontinue blood gas. If ketone is negative, discontinue ketone test.) |
DKA: diabetic ketoacidosis; PICU: pediatric intensive care unit.