June 2022 – Version 1.

PICU Management of DKA:

Kuwait PICU Taskforce Guideline
Mohammad Alzaibak, Ahmad Almosawi, Fajer Altammar, Mohammad Othman, Ahmad Ibrahim,
Abdullah Alfraij, Hashem Al-Hashemi
Reviewed & approved by Kuwait MOH Pediatric Endocrine Experts group

Definition (must include all of the following): Severity

Defining
Hyperglycemia: Blood Glucose > 11 mmol/L Mild Moderate Severe
features
Metabolic acidosis: Venous pH < 7.3 or serum HCO3 < 15 mmol/L
Ketosis: Presence of ketones in blood (β-hydroxybutyrate ≥ 3 mmol/L) Venous pH 7.20 - 7.29 7.10 - 7.19 < 7.1
or urine (urine ketones ≥ +2) HCO3 10 - <15 5-9 <5

Assessment and Management

Initial Assessment Initial Resuscitation

• Check ABC, vital signs, GCS, and level of consciousness, weight,
and clinical signs of dehydration.
• Check Capillary glucose, blood ketone
• Obtain Two IV access
• Stat investigations
• Serum glucose, blood gas, Na, K, HCO3, Urea, Creatinine,
CBC, Ca, PO4, Mg.
• For NEWLY diagnosed DM (before starting insulin infusion):
Insulin level, C-peptide, anti-insulin Ab, HbA1C
• If an infection is suspected: CBC, CRP or PCT, Cultures
• For NEWLY diagnosed DM, the rest of the endocrine blood work to
be done after patient is stable and discharged from PICU.
• For ALL patients with DKA → give an initial fluid
bolus of 0.9% NS, 10 ml/kg over 30 min.
• For patients in persistent shock (hypotension,
weak pulses, prolonged capillary refill time,
decreased level of consciousness) → give a
second fluid bolus of 0.9% NS of 10 - 20 ml/kg
over 30 min.
• Consider whether IV antibiotics are necessary

Fluids and Insulin

Rehydration fluids (use current weight NOT ideal body weight) Initial insulin infusion (at least 1 hour after
initial fluid replacement therapy)
• Start 0.9% NS (see rate according Weight TFI (ml/kg/h) AND
to weight in the right table) (kg) Include insulin rate
• Add desired potassium (refer to •Start continuous insulin infusion at 0.05 u/kg/h∆
potassium adjustment table) 4-9 6.5 For insulin preparation*, Consider either:
[25 units of regular insulin to 250 ml of 0.9% NS]
10-19 6 OR
• Adjust Dextrose content depending
on glucose level (refer to the Two- 20-39 5 [50 units of regular insulin to 50 ml of 0.9% NS]
Bag technique table on the next *flush tubing and syringe with 20 ml of this preparation
page) ≥ 40 4 (Max 200ml/h)‡ ∆ 0.05u/kg/h insulin is non-inferior to 0.1u/kg/hr and has

‡ been associated with less therapy related complications

Some Pediatric centers use a maximum TFI of 250 ml/h
such as hypokalemia and hypoglycemia.

Monitoring Potassium (K+)

•Hourly: blood glucose level, vital signs, Input/output chart, K+ Level Add
[Potassium component (mmol/L) of each fluid bag is
Neurological assessment/NeuroVitals (headache, irritability, LOC, (mmol/L) preferred to be divided equally between KCl and Kphos]
pupils, GCS).
•Q2h: Blood Gas Analysis (BGA), electrolytes in BGA 3.5- 4.9 40 mmol/L
•Q4h: Urea, Creatinine, electrolytes (calculate corrected* Na),
Mg, PO4, Ca, ketones (blood is preferred), Anion Gap (AG), < 3.5 60 mmol/L
serum osmolality. severe If persists despite a max. rate of potassium
*Corrected Na= measured Na + 1.6 x ([glucose in mmol/L-5.6] /5.6)
hypok+ replacement, then the rate of insulin can be reduced.

Phosphate (PO4)
• Severe hypophosphatemia [< 1 mg/dL (0.32 mmol/L)] with or without associated symptoms should be treated.
Note: administration of phosphate may increase the risk of hypocalcemia hence close monitoring of calcium is needed.
 June 2022 – Version 1.0

PICU Management of DKA:

Kuwait PICU Taskforce Guideline
Mohammad Alzaibak, Ahmad Almosawi, Fajer Altammar, Mohammad Othman, Ahmad Ibrahim,
Abdullah Alfraij, Hashem Al-Hashemi
Reviewed & approved by Kuwait MOH Pediatric Endocrine Experts group

Ongoing IVF management (Two-bag Technique)

Current Drop in glucose in the last Bag 1 Bag 2 Dextrose Net

glucose hour 10% Dextrose + (0.9% Result
level (glucose should not drop > 5 (No Dextrose) NaCl OR Ringer’s lactate) + (after combining
(mmol/L) mmol/L per hour) 0.9% NaCl + desired K desired K (same K in bag1) Bag 1 + 2 rates)

<5
100% of fluid rate 0% of fluid rate D 0%
OR glucose has increased
> 18
5-8 50% 50% D 5%
>8 0% 100% D 10%
<5
75% 25% D 2.5%
15 -18 OR glucose has increased
≥5 0% 100% D 10%
<5
50% 50% D 5%
12-14.9 OR glucose has increased
>5 0% 100% D 10 %
<5 25% 75% D 7.5%
9-11.9
>5 0% 100% D 10%
<9 Any change 0% 100% D 10%
* This table provides a guide to fluid management. This 2-bag technique is an efficient way to deliver varying concentrations of Dextrose
depending on the patient’s rate of glucose change. If Dextrose 12.5% is required, manage as per usual.

Important Considerations

Avoid (if possible) Persistent Acidosis (despite treatment)

• Avoid intubation [as mechanical ventilation
will affect physiological CO2 compensation].
• Avoid placing Central Venous Catheter
(CVC) [Risk of thrombosis]
• Avoid giving insulin through CVC once
placed. [Large dead space in CVC may cause
erratic insulin delivery].
• Urinary catheter is not necessary.
• Calculate Anion Gap (AG). For normal AG metabolic acidosis, Consider
changing 0.9% NaCl to RL or 0.45% NaCl to reduce the chloride load.
• Review insulin infusion (dose, expiry date, preparation, change IV
tubes).
• Prepare new insulin infusion and flush tubing.
• Consider differential diagnosis, including infection.
• Re-discuss the case with a pediatric endocrinologist.

Neurological deterioration

Cerebral Edema Management

Assessment
1. Rule out hypoglycemia.
2. Consider Cerebral Edema:
Irritability, headache,
seizure, decreased LOC,
unreactive or asymmetric
pupils, bradycardia,
hypothermia, hypertension,
urinary incontinence (for
older patients)
• DO NOT wait for the CT head. Treat immediately.
• If focal neurological deficits develop; then an urgent CT scan is warranted to rule out
cerebral venous thrombosis or intracranial hemorrhage (ICH).
• Elevate head of the bed to 30 degrees, head in a midline position to facilitate cerebral
venous drainage.
• Give 3% NaCl at 5 ml/kg over 10 min (max 250 ml) OR 20% mannitol at 0.5-1 gm/kg
(5ml/kg) over 10-15 min. Repeated dosing of either 3% NaCl or Mannitol after 30 min from
the first dose may be required if no response. [There is no evidence to suggest whether
mannitol or 3% NaCl is the first line choice. Consider Na trend and your resources].
• Reduce TFI to 60% of the requirement
• Consider intubation for impending respiratory failure