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Diabetic Ketoacidosis (DKA) Clinical Pathway – Emergency Department, ICU and Inpatient

Emergency Department, ICU and Inpatient Clinical Pathway for
Evaluation/Treatment of Children with Suspected Diabetic Ketoacidosis (DKA)

Goals and Metrics
Patient Education
Provider Resources
Cerebral Edema Risk, Treatment
Child with Suspected DKA
 
 
 
60 min
ED Triage
POC glucose, POC beta-hydroxybutyrate (BOHB)
 
 

Team Assessment

 
 
  • DKA Confirmed
    • Glucose > 200 mg/dL and
    • BOHB > 3 mmol and
    • pH < 7.3 or HCO3 < 15 mmol/L
 
 
Ongoing Treatment
  • Care Goals
    • Frequent MS, VS, PE assessment
    • Initial NS bolus over 1st hr
    • Insulin to start after 1st NS bolus
    • Decrease blood glucose (BG)
      • 50–100 mg/dL/hr
    • Adjust dextrose
      • Based on hourly BG
    • Adjust K+
      • Based on q2hr BMP/mag/phos
      • ECG for < 2.5 or K > 6
 
 
IVF Rehydration, Electrolytes, Glucose
  • Additional NS or LR bolus as indicated by PE, VS
  • Start NS 1.5x maintenance until electrolyte results
    • If glucose required prior to electrolyte results, use D10 0.45% NaCl
    • Provide dextrose based on BG as below
      • e.g., BG 200–299, use Half D10 0.45% NaCl + Half 0.9% NaCl
  • Then start 2 bag system: D10 0.9% NaCl, 0.9% NaCl with electrolytes as below
    • Dextrose provided based on BG
    • Electrolyte content based on K+ level
    • Rate 1.5x maintenance
Glucose Concentration in IVF
Blood Glucose Dextrose
< 200 All D10 0.9% NaCl
200–299
  • Half D10 0.9% NaCl
  • Half 0.9% NaCl
≥ 300 All 0.9% NaCl
Concentration of Potassium in IVF: KCL + KPhos
Serum K KCL KPhos
< 4 30 mEq 30 mEq, 20.4 mM
4–5.4 20 mEq 20 mEq, 13.6 mM
5.5–6 10 mEq 10 mEq, 6.8 mM
> 6 None None
Electrolyte Abnormalities in DKA
Na HCO3 is not recommended
Regular Insulin Infusion
  • Start regular insulin 0.1 units/kg/hr after initial NS bolus completed
  • Stop home insulin pump
  • Review Lantus dosing with Endocrine
Labs Monitoring
  • POC BG hourly
  • BMP/mag/phos and POC BOHB q2hr
  • VBG q2hr until pH > 7.0
Physical Monitoring
  • Full Cardiorespiratory Monitoring
  • VS, neuro assessment hourly
Admission Considerations
 
 
  • Resolution of DKA
    • MS, VS improved, tolerating sips
    • HCO3 ≥ 15 mmol/L or < 15, BOHB < 2mmol/L
    • Anion gap < 10