1

Management Guideline
for
Diabetic Ketoacidosis
of
Childhood and Adolescence

2544

Diabetic Ketoacidosis (DKA)

insulin

insulin
1.
Hyperglycemia glucose
gluconeogenesis glycogenolysis glucose
(underutilization)
2. Ketosis lipolysis ketogenesis
ketonemia
3. Hypertriglyceridemia free fatty acid
4. Osmotic diuresis hyperglycemia
glucose, sodium potassium electrolyte imbalance
5. Volume depletion hyperglycemia, glucosuria
osmotic diuresis dehydration

type I DM DKA

- (hyperglycemia)
(polydipsia), (polyuria),
(nocturnal
enuresis)
- , (weight loss), (weakness)
(stress)
precipitating factor DKA
(Kussmaul breathing) metabolic
acidosis (coma) dehydration
acetone
DKA
1. Serum glucose >250 mg/dl
2. Acidosis : HCO3 <15 mmol/L arterial pH <7.30
venous pH <7.25
3. Ketone : positive ketone

1.
2.
. blood glucose ( ketone )
. urine ketone glucose
. blood gas pH, pCO2, base excess (),
arterial pH
venous pH 0.05
3. (assessment of degree of dehydration)

DKA
1. 0.9% NaCl, 0.45% NaCl, 5% dextrose
0.3% NaCl, 2.5%
dextrose 0.45% NaCl
2. electrolyte KCl vial (1 ml = 2 mmol),
KH2PO4 vial (1 ml = K 2 mmol) PO4 ,
NaHCO3 vial (1 ml = HCO3 1 mmol)
3. insulin short acting insulin regular insulin
(RI)
4. Intravenous-drip set
5. Infusion pump
6. Flow sheet
7. (blood glucose meter) (test strips)
ketone (ketodiastix)

initial investigation
For DKA
1. Glucose ketone
2. Serum electrolyte, BUN, Cr, Ca, PO4 CBC
3. Blood gas ( severe DKA, coma) capillary
arterial blood gas
4. EKG hypo hyperkalemia
For precipitating cause

1. Hemoculture
2. Urinalysis
3. CXR if indicated

For DM
1. HbA1c
2. Insulin C-peptide
3. Insulin autoantibody (IAA), Islet cell antibody (ICA),
Anti GAD
2, 3 ()

DKA
1. fluid dehydration
. degree of dehydration DKA

dehydration 7 10 %
. impending shock ,
, initial rehydration 0.9% NaCl 10
20 ml/kg/hr 1 2 50 ml/kg 4
. fluid maintenance + deficit (7 10%)
36 48 (fluid dehydration fluid
initial rehydration 1-2 .. ) 0.45% NaCl
( 0.9% NaCl 0.45% NaCl
hypernatremia ) fluid 24 4 //
1. 0.9% NaCl
2. corrected serum Na (Na < 130 mmol/L)
( Na) 0.9% NaCl
serum electrolyte
3. increased intracranial pressure
hypernatremia (Na >150 mmol/L) deficit 48
0.45% NaCl fluid osmolality
fluid cerebral edema

. KCl initial rehydration insulin

injection renal failure /
hyperkalemia serum K > 6 mmol/L KCl 3
. fluid balance
re-evaluate fluid status 2 3
. NPO DKA
( mild DKA )
2. insulin replacement
insulin initial rehydration regular
insulin (RI) 2
1)
Continuous low-dose intravenous insulin infusion
method
. regular insulin 0.1 unit/kg/hr insulin
infusion RI 50 unit 0.9 % NaCl 500 ml RI
1 unit 10 ml 1 ml RI 0.1 unit RI 50
unit 50 ml 1 ml RI 1 unit insulin infusion
infusion pump dose insulin side
line fluid insulin plastic infusion
set insulin insulin infusion 30 50
ml saturate binding site
1. insulin IV bolus insulin infusion
2. initial rehydration RI
infusion 50-200 mg/dl dehydration
RI
. blood glucose 75 100 mg/dl

. monitor hypoglycemia
bedside blood glucose 1
. blood glucose 250-300 mg/dl
rehydration fluid 5% dextrose 0.45% NaCl

insulin infusion dextrose blood glucose

120- 250 mg/dl
. Insulin infusion acidosis
ketonemia insulin 5% dextrose
blood glucose 150- 250 mg/dl blood glucose
( 150 mg/dl) insulin (
0.05 unit/kg/hr) dextrose 7.5 10%
ketonemia acidosis insulin
insulin infusion
subcutaneous (SC) insulin SC dose -1
insulin infusion insulin rebound
hyperglycemia
2) Intramuscular (IM) insulin administration
. RI 0.1 unit/kg IM 1 blood glucose
250 300 mg/dl RI 0.25 - 0.5 unit/kg SC 4 6
infusion pump
severe acidosis, peripheral perfusion
insulin
. insulin IM continuous
insulin infusion 1-2 . fluid
replacement 1)
3. potassium (K)
. Potassium insulin
DKA total body K K
initial rehydration K 6 mmol/L
EKG tall peak T wave
Serum K (mmol/L)
< 3.5
3.5 5.4
5.5 6

K fluid 1
(mmol)
60
40
20

K 0.3 mmol/Kg/hr
. K KCl KH2PO4
DKA phosphate phosphate
2,3-diphosphoglycerate shift oxyhemoglobin
dissociation curve oxygen
hyperchloremia ( phosphate)
. severe acidosis serum K < 3 mmol/L
severe potassium
depletion K insulin
cardiac arrhythmia severe hypokalemia KCl 20
30 mmol fluid 1 3
4. sodium (Na)
serum Na DKA blood glucose
corrected sodium
Corrected Na = Na (mmol/L) + (Blood glucose
(mg/dl)100)x 1.6
100
serum Na 150 mmol/L
hypernatremia hyperosmolar Na glucose
cerebral edema
fluid deficit 48
corrected Na 160 mmol/L hyperlipidaemia
psuedohyponatremia
5. bicarbonate (HCO3)
. acidosis fluid dehydration

insulin bicarbonate HCO3

cerebral edema

(1)

(2) Severe acidosis pH < 7.0 blood gas

HCO3 < 8 mmol/L
HCO3 deficit

7.5% NaHCO3 (ml) = 1/3 x0.3 x base excess x

BW (kg)
intravenous drip

blood gas NaHCO3

7.5% NaHCO3 (ml) = 0.3 x BW (kg) x (10HCO3)
HCO3 10 mmol/L
. bicarbonate paradoxical
cerebral acidosis,
shift to the left of oxyhemoglobin dissociation curve
peripheral oxygen availability
severe hypokalemia K
monitor EKG
6. phosphate (PO4)
DKA PO4 deficit serum PO4
acidosis insulin serum PO4 PO4

PO4
hypocalcemia serum
PO4 1 mg/dl
PO4 KH2PO4 20-30 mmol/L
serum Ca PO4

7. monitor
DKA
ICU

. vital sign neurosign 1 .

. blood glucose 1 .
. serum electrolyte, blood gas () 2 4 .
. intake output 2 4 .
. urine ketone 6 .
250 mg/dl
. serum BUN, Cr, Ca, PO4 severe DKA
. flowsheet
. naso-gastric tube urinary
catheter
8. precipitating factor
antibiotics routine DKA
bacterial infection
urinalysis, urine culture, CXR,
hemoculture, tuberculin test
9.
DKA
. Hypoglycemia continuous insulin
infusion monitor blood glucose
. Persistent acidosis HCO3 < 10 mmol/L
8 10 hyperglycemia

- insulin insulin
insulin intramuscular intravenous
infusion
- Imbalanced fluid intake
- Infection
- hyponatremia, hypokalemia hyperchloremic
acidosis chloride
- Insulin
. Hypokalemia K
acidosis K shift K

K K
muscle weakness
. Intracranial complication brain edema
24
< 5 brain edema
decreased sensorium, sudden and severe headache, incontinence,
vomiting, disorientation, agitation, changes in vital signs,
pupillary change, ophthalmoplegia, papilledema, seizures
< 5 severe DKA
1) monitor ICU
2) cerebral edema
- Mannitol 1 2 g/kg intravenous infusion
- Intubation hyperventilation
coma
- Monitor neurological sign CT
brain
DKA
1. fluid replacement
( ) metabolic
blood glucose <300 mg/dl, pH > 7.3 serum
HCO3 > 15 mmol/L ketosis
2. insulin infusion

metabolic blood glucose < 300 mg/dl, pH > 7.3
serum HCO3 > 15 mmol/L regular insulin subcutaneous
0.25 0.5 unit/kg insulin infusion

3. subcutaneous regular insulin

subcutaneous regular insulin 0.25 0.5 unit/kg/dose
3 1 2 acidosis regular
insulin intermediate acting insulin (NPH)
total dose insulin 0.7 1.0 unit/kg/day 2 3

10

( NPH : regular insulin 2 : 1) 1 3

( NPH : regular insulin 1 : 1)
4.

carbohydrate 50 55% , fat 25 30%, protein 1520%

5. ketone
blood glucose , , , ,
3 hypoglycemia urine
ketone blood glucose > 250 mg/dl
insulin 70 180 mg/dl
6. DKA

.
. Insulin insulin
.
.
. hypoglycemia hyperglycemia
.

1 2

1. , . : ,
, , , ().

3. : , 2542 : 2203-15.
2. . Diabetic ketoacidosis : , ,

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: , 2542 : 2216-23.
3. Brink SJ. Presentation and ketoacidosis. In : Kelnar CJH. (ed).
Childhood and adolescent

11

diabetes. 1st ed . London. Chapman Hall, 1995:213-39.

4. Fairchild J. Insulin infusion protocol for diabetic ketoacidosis
in childhood and adolescence.
Diabetes Center, The Ray William Institute of Pediatric
Endocrinology, Pediatric and
Metabolic Jan 1990.
5. Brenchley S, Govindji A. Dietary management of children
with diabetes. In : kelnar CJH (ed).
Childhood and adolescent diabeties, 1st ed. Candon. Chapman
Hall. 1995:271-81.
6. Kuzuya T. Diabetic ketoacidosis and nonketotic
hyperglycemia. In : Turtle JR et al.(ed)
Diabetes in the new millennium. Sydney: The Pot Still Press,
1999: 297-306.
7. Glaser N, Barnett P, McCaslin I, Nelson D, Trainor J, Louie J,
et al. Risk factors for cerebral edema in children with diabetic
ketoacidosis. N Engl J Med 2001; 344:264-9.
8. International Society for Pediatric and Adolescent Diabetes.
Diabetic ketoacidosis. In :
Consensus guidelines 2000. Zeist : Medical forum
international, 2000:63-73.
9. American Diabetes Association. Hyperglycemic crises in
patients with diabetes mellitus.
Diab Care 2001; 24(Suppl 1):S83-90.
10. White NH. Diabetic ketoacidosis in children. Endocrinol
Metab Clin North Am 2000;
29:657-82.

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