Paediatric DKA

Paediatric DKA management differs critically from adults — fluid must be given more cautiously due to the risk of cerebral oedema, the most feared complication. Do NOT bolus more than 10ml/kg (20ml/kg only in shock). Use the BSPED 2020 protocol. All…

BSPED DKA Guideline 2020

The pathway

1 · Initial fluid bolus

In shock (weak thready pulse, hypotension): 10ml/kg 0.9% NaCl as soon as possible. Do NOT subtract it from the deficit
Dehydrated but not shocked: 10ml/kg 0.9% NaCl over 30 min, and DO subtract it from the deficit
A second 10ml/kg only after reassessment, and discuss with the responsible senior paediatrician first

2 · Fluid replacement (BSPED 2020)

Mild: 5% deficit
Moderate: 7% deficit
Severe: 10% deficit

Add to 48h maintenance. Give as 0.9% NaCl. Do NOT use hypotonic fluids. Subtract any resus bolus given.

3 · Insulin

Start insulin infusion 0.05–0.1 units/kg/hr 1–2 hours after IV fluids begin — not before, not at the same time. Do NOT give bolus insulin. Target glucose fall of 2–5 mmol/L/hr. When glucose <14, change fluids to 0.9% NaCl + 5% glucose + 40mmol/L KCl rather than stopping insulin.

4 · Potassium

K+ <3.5: 0.4 mmol/kg/hr
K+ 3.5–5.5: 0.2 mmol/kg/hr
K+ >5.5: no potassium yet

ECG monitoring required.

5 · Monitor for cerebral oedema

Headache, bradycardia, falling GCS, rising BP — cerebral oedema until proven otherwise. Give mannitol 0.5–1g/kg IV immediately. Reduce fluid rate by 30%. Call PICU.

6 · Resolution criteria

pH >7.3
Bicarbonate >15
Blood ketones <1 mmol/L
Tolerating oral fluids

Switch to SC insulin before stopping infusion (30–60 min overlap).

Drugs

Drug	Dose	Route	Notes
0.9% NaCl	Calculated deficit + maintenance	IV	48h replacement. Do NOT use 0.45% NaCl initially. Add glucose when BG <14 mmol/L.
Insulin (Actrapid)	0.05–0.1 units/kg/hr	IV infusion	Start 1–2 hours after fluids begin. Never bolus. May be reduced to 0.05 units/kg/hr — the unit is units/kg/hour, not units — if glucose is falling faster than 5 mmol/L/hr.
Potassium chloride	0.2–0.4 mmol/kg/hr	IV (in fluids)	Max 0.4 mmol/kg/hr. ECG monitoring if high rate.
Mannitol 20%	0.5–1g/kg (2.5–5ml/kg)	IV over 15 min	For cerebral oedema — give immediately, call PICU.

When to escalate

Cerebral oedema signs (bradycardia, falling GCS, headache) — mannitol + PICU immediately,pH <7.1 or bicarbonate <5 — senior review, consider HDU,Shock unresponsive to two 10ml/kg boluses — PICU,Age <2 years — always PICU

Reference: BSPED DKA Guideline 2020 / ISPAD Guidelines 2022

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