Pediatric DKA: A Quick Blurb
A previously healthy 6-year-old female presents with nausea, vomiting, and abdominal pain. She is ill-appearing, tachypneic, tachycardic, with dry mucous membranes. She is ultimately found to be severely acidotic and hyperglycemic with ketonuria, glucosuria, and a severely elevated BHB. You’ve made the presumptive diagnosis of new onset T1DM with DKA. Now what?
The mainstays of treatment, as with adult patients, are IVF resuscitation, insulin therapy, and electrolyte replacement. However, how should we think about these in specifically pediatric DKA? This is an abbreviated summary–I recommend you review the references for more information and context.
Question: What to know about fluids?
At the time of presentation, most children in DKA are typically 5-10% dehydrated due to osmotic diuresis. Physical exam and vitals signs often underestimate the fluid deficit.
Initial Resuscitation: 10 cc/kg of NS over 1 hour to improve circulatory volume. Can consider an additional 10-20 cc/kg NS bolus as indicated by vitals signs, mental status, and the physical exam.
Maintenance Fluids: After the initial bolus, begin NS at 1.5x maintenance until BMP is available, potassium is known, and insulin administration can begin.
More recent data suggests that neither the rate nor the sodium content of the fluids used for fluid resuscitation are associated with an increased risk of cerebral edema. Fluid resuscitation should be based on hydration status and hemodynamics.
Question: What about electrolytes?
As with adult patients, expect a total body potassium repletion. It is important to identify the serum potassium before initiating insulin due to the risk of precipitating symptomatic hypokalemia.
When the potassium is below 5-5.5 mEq/L (institution dependent), begin potassium supplementation. It is recommended that 40 mEq of potassium-equivalents are incorporated into each liter of fluid. Repletion may need to be more aggressive at a lower potassium, especially less than 4.0 mEq/L
Many protocols use a combination of potassium phosphate or potassium acetate over potassium chloride to limit hyperchloremia.
BMP/Mg/Phos should be checked every 2-4 hours.
Question: “What is the two-bag system for pediatric DKA management?”
Using the 1.5 x maintenance rate, fluids come from 2 separate bags–a saline bag and a glucose bag.
Bag #1: Crystalloid. Institutions vary on the use of NS or 1/2NS. These fluids should contain potassium.
Bag #2. Glucose. This bag should contain D10 and have the same electrolyte composition as bag #1.
As the glucose decreases in the presence of volume resuscitation and insulin, the percentage of the 1.5x maintenance infusion coming from the glucose containing bag increases. This allows continued insulin therapy to decrease the ketoacidosis while preventing hypoglycemia.
Given children are more at risk for hypokalemia, hypoglycemia, and cerebral edema than adults, this two-bag system can facilitate adjustments in a dextrose infusion while maintaining a constant rate of fluid administration.
Question: “What about insulin therapy”
For those patients with moderate to severe DKA, start regular insulin at 0.5-0.1 units/kg/hr after initial bolus is completed and the potassium level has resulted.
Insulin boluses should be AVOIDED in pediatric DKA.
Insulin should be continued until DKA has resolved and then patients should be transitioned to subcutaneous insulin.
Cheers,
Dillon
Resources Cited:
Tzimenatos, L., & Nigrovic, L. E. (2021). Managing Diabetic Ketoacidosis in Children. Annals of emergency medicine, 78(3), 340–345. https://doi.org/10.1016/j.annemergmed.2021.02.028
https://www.aliem.com/pediatric-diabetic-ketoacidosis-two-bag-method/
https://www.chop.edu/clinical-pathway/diabetes-type1-with-dka-clinical-pathway
