DKA diagnostic criteria (ISPAD) (Hyperglycemia BG >11 mmol/L (200 mg/dL) AND acidosis (pH <7.3 or bicarbonate <15 mmol/L) AND ketonemia/ketonuria — all three required (ISPAD 2022/2024, BSPED, NICE NG18))
Mild / moderate severity (Mild: pH 7.20–7.30 or HCO3 10–15 mmol/L · Moderate: pH 7.10–7.19 or HCO3 5–9 mmol/L · **No shock** — do NOT give routine fluid bolus; start gradual IV rehydration over 48 h (ISPAD 2022, AAP, BSPED))
Max 500 mg/dose · Duration: 48 h · Initial rate ~10 mL/kg/h (calculator: mL/h = 10 × weight kg) — then adjust per 48-h deficit+maintenance plan; **not** a bolus; avoid sustained rates >10 mL/kg/h (ISPAD 2022, BSPED)
• **NO routine fluid bolus** — ISPAD 2022/2024 explicitly recommends against bolus fluids in hemodynamically stable DKA; bolus only for true shock (see severe variant). Rapid fluid administration increases cerebral edema risk (ISPAD, BSPED, NICE NG18).
• **Fluid deficit + maintenance over 48 h (ISPAD):** estimated deficit (mL) = weight (kg) × dehydration % × 10; dehydration estimate: mild ~5%, moderate ~7%, severe ~10% (clinical assessment ± corrected Na+). Maintenance (Holliday-Segar, 24 h): 100 mL/kg for first 10 kg + 50 mL/kg for next 10 kg + 20 mL/kg for each kg >20. **Total 48-h volume (mL) = (maintenance × 2) + deficit**. **Hourly rate (mL/h) = total ÷ 48**; typical initial rate ~5–10 mL/kg/h — avoid rates >10 mL/kg/h sustained; reduce rate if BG falling >5 mmol/L/h or cerebral edema suspected (ISPAD 2022, BSPED).
• **NO insulin bolus** — ISPAD recommends against initial IV insulin bolus; bolus causes rapid osmotic shifts and may worsen cerebral edema risk. Start continuous IV infusion **0.05 U/kg/h** (range 0.05–0.1 U/kg/h) **1–2 hours after starting fluids** OR when serum K+ is known and ≥3.3 mmol/L; if K+ <3.3 mmol/L, rehydrate and replace K+ before insulin (ISPAD 2022/2024, AAP, NICE).
• **Potassium:** add to IV fluids when K+ <5.5 mmol/L **and** urine output established — typical replacement **20–40 mmol/L** of fluid; max peripheral concentration usually **40 mmol/L** (check local policy; higher via central line only). **Never bolus K+ in DKA.** If K+ <3.3 mmol/L hold insulin and give K+ first; if K+ >5.5 mmol/L do not add K+ until levels fall and urine output present (ISPAD, BSPED, NICE NG18).
• **Glucose-containing fluids:** when BG falls to **<14–17 mmol/L (250–300 mg/dL)** add dextrose (typically **D5** or **D10** in 0.45% or 0.9% NaCl) — **continue insulin infusion** to clear ketosis; titrate dextrose concentration to maintain BG 8–14 mmol/L while ketosis resolves; do not stop insulin until acidosis resolves (ISPAD 2022, BSPED, ESPE).
Max 1 mg/dose · Duration: Ongoing · Start SC when pH >7.15, HCO3 >15 mmol/L, anion gap closed, tolerating PO — give basal (e.g. glargine 0.25–0.5 U/kg/day) + prandial rapid-acting; continue IV insulin 1–2 h after first SC dose to avoid rebound (ISPAD 2022, BSPED, NICE)
• SC insulin transition: pH >7.15, bicarbonate >15 mmol/L, anion gap closed/near-closed, BG stable on dextrose-containing fluids, tolerating oral intake — overlap IV insulin 1–2 h after first SC basal dose; involve pediatric endocrinology (ISPAD 2022, BSPED, NICE NG18).
• Increase insulin rate to 0.1 U/kg/h: if BG not falling by 3 mmol/L in first hour **and** no hypoglycemia — reassess fluid rate and insulin delivery; do NOT use bolus (ISPAD 2022).
• Bicarbonate: NOT preferred in routine DKA — reserved for specialist-directed extreme acidosis (pH <6.9) with hemodynamic compromise or life-threatening hyperkalemia; routine use associated with worse outcomes (ISPAD, BSPED, AAP).
• Phosphate replacement: NOT routine — consider only if symptomatic hypophosphatemia (weakness, respiratory failure, rhabdomyolysis) under specialist care (ISPAD 2022).
• PICU/endocrinology consult: all moderate DKA; any child <2 years; new-onset diabetes with severe presentation; social or compliance concerns; or failure to improve within 12–24 h (ISPAD, BSPED, NICE).
Enter weight on Kids to calculate doses
Clinical notes
• DKA diagnostic criteria (ISPAD): hyperglycemia BG >11 mmol/L (200 mg/dL) + acidosis (pH <7.3 or HCO3 <15 mmol/L) + ketonemia/ketonuria — severity: mild pH 7.20–7.30 or HCO3 10–15; moderate pH 7.10–7.19 or HCO3 5–9; severe pH <7.10 or HCO3 <5 (ISPAD 2022/2024, BSPED, NICE NG18).
• Cerebral edema warning signs: headache (often severe, progressive), vomiting after initial improvement, altered mental status (irritability, drowsiness, confusion), bradycardia, hypertension, age-inappropriate incontinence, focal neurologic signs, papilledema — treat as emergency even in mild–moderate DKA (ISPAD 2022, BSPED).
• Cerebral edema suspected: **reduce IV fluid rate**, elevate head 30°, mannitol **0.5–1 g/kg** IV over 15–20 min OR hypertonic saline **2.7–5% 2.5–5 mL/kg** over 10–15 min; call PICU/senior immediately; **do NOT** give bicarbonate or routine intubation/hyperventilation (ISPAD 2022/2024, BSPED).
• PICU criteria: severe DKA (pH <7.1, HCO3 <5), age **<2 years**, shock, altered consciousness/GCS decline, suspected cerebral edema, need for mechanical ventilation, or inadequate response to ward-level care — early endocrinology and PICU involvement (ISPAD, BSPED, NICE, AAP).
• ISPAD — Consensus Guidelines for DKA and hyperglycemic crises in children and adolescents (2022)
