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DKA protocol for Emergency and critical unit of Tikur

Anbessa Specialized Hospital (TASH)

By Tigist Bacha MD, MPH

Consultant pediatric emergency and crital care
Definition
Diabetic ketoacidosis is the (acute complication) most important complication of Diabetes mellitus from
absolute or relative deficiency of circulating insulin and the combined effects of increased levels of the
counter regulatory hormones. This results is high blood glucose level which intern leads to excessive
diuresis which again leads the patient to lose excess water and electrolyte (especially potassium ). This
finally results in sever dehydration / shock and a total body potassum lose . The stress response to insulin
deficiency also causes fat tissue to broken down into free fatty acids which intern converted into ketoacids
in the liver. To remove the acidosis the body will do deep and fast actetone breathing ( Kussmol breathing ) .

Clinical presentation
The Patients may present of increased urination ( polyuria) , increased trust (polydypsia) and increased
appetite ( polyphagia) may be present -history of weight loss, nausea; vomiting; and abdominal pain, deep
and fast breathing which has fruity smell , an altered state of consciousness and signs of dehydration and /or
shock.
New-onset diabetes with , presenting clinical features can be misdiagnosed, especially in the infant or young
child. Abdominal pain may be considered as appendicitis; may be mistaken as a sign of pneumonia or
asthma; and polyuria may be incorrectly diagnosed as a urinary infection ,enuresis and polydipsia.

Diagnostic Criteria for DKA

 Clincal presentation as above plus the below biomedical conditions (parameters)

 Glucose value (RBS) >200 mg/dL
 positive urine ketones (moderate or large) >= +2.
Investigation:

 RBS , urine analysis one( ketone ,glucose ) ( for ket ,Serum electrolyte(calcium,
phosphorus, and magnesium ,potassum .sodium), Bun ,creatine , other investigation may be
required depending on the precipitating factor consider as you see later in this session, or
blood count, concentrations. The cause of a high white blood cell count is more often stress
than infection.
If the setting allows osmolality, venous (or arterial in critically ill patient) pH, ,pCO2,
 Perform a urinalysis or blood test for ketones
CLASSIFICATION OF DIABETIC KETOACIDOSIS

NORMAL MILD MODERATE SEVERE[†]

Kussmaul respirations;
No Oriented, alert Kussmaul or depressed respirations;
Clinical oriented but sleepy;
change but fatigued sleepy to depressed sensorium to coma
arousable

PH

Bicarbonate

Management

1. Resustation ( ABCD )

2. Expand intravascular volume

3. Potassium replacement therapy

4. Insulin therapy

5.Treat complications

6. Treat precipitating factors

7. Monitoring

1 General Resuscitation Measure

A= position the airway, Secure the airway and empty the stomach by continuous nasogastric suction to
prevent pulmonary aspiration in the unconscious patient.
B=Give 100 % of oxygen by face mask

C= For patients who are severely and moderate DKA who are volume depleted but not in shock, volume
expansion (resuscitation) should begin immediately with 0.9% saline administered 10 ml/kg over 1hour , and
may be repeated if necessary.

In the rare patient with DKA who presents in shock , rapidly restore circulatory volume with isotonic saline in
20 ml/kg bolus infused as quickly as possible through a large bore cannula if not possible intaosseous . Repeat
if necessary, with careful reassessment after each bolus. Secure Intraosseous. If attempts to get IV access
have failed. Take blood sample simultaneously with IV administration give depending on the response of the
child shock status (cool, pale extremity, hypotension and tachycardia) repeat bolus .Then address the fluid
management as below.
2. Expand intravascular volume

2.1 calculate the fluid required

For moderate and severe DKA calculate the fluid required in the next 48 hours as follows. These fluid
includes the maintenance fluid (a daily requirement of child) and the deficit which is the one the patient lost
need

Maintenance fluid (48 hours) + Deficit fluid ( 85 X Wt)- Minus Bolus fluid ( which you gave above )

= --------ml/ 48hr.

See table below to calculate maintence fluid amount

Table Calculation of maintence fluid

Weight Amount of IV fluid for maintence Rate of adminstration

The first 10 KG 100ml/kg /24hour

From 10 kg to 20 kg 1000ml + 50ml/kg ( for kg above

10 kg)

eg 13 kg = 1000ml+3x50ml=1150

Above 20 kg 1500ml+ 20ml/kg above the 20kg

eg 22k child : 1500ml+20mlX 2kg

=1540ml

2.2 The type of fluid

 Use full strength NS in the first one hour bolus and use normal saline till Fluid management
(deficit replacement) should be with 0.9% saline for at least 4-6 hours. After 4- hours of fluid and /or
when the random blood sugar reaches 300gm/dl change the fluid to ½ strength saline in 5% DW (
make ½ fluid NS and ½ normal saline )

 Use half strength N/S for the rest of the 48 Hrs fluid and fluid less than the 0.45NS ( ½ strength
saline) should not be used .The next 48 hour the fluid management should be always should be with
a solution that has a tonicity equal to or greater than 0.45% saline .

 All this above fluid should contain deficit replacement of potassium as discussed below .
 As long as the child remains acidotic, insulin administration should never be stopped .if instead drop
in the blood sugar need to be addressed by adding or increasing glucose administration in the IV
fluid; maintain the blood glucose between 150 and 250 mg per dL. Therefore use If blood glucose
drops belo w 300mg/dl Change fluid to 5% DW in ½ NS( half of the fluid NS and half DW ) or use
DNS

 Catheterize the bladder if the child is unconscious or unable to void on demand (e.g. infants and
very ill young children).

 Oral fluids should be introduced only when substantial clinical improvement has occurred (mild
acidosis/ketosis may still be present).

3. Potassium replacement therapy

 All children with DKA have total body potassium depleted; therefore, potassium replacement is
required regardless of the serum potassium concentration. When the patient pass adequate urine
amount start Potassum 40 mmol in 1000 ml of the maintenance .

 If you are able to measure potassum( only if rapid blood gas and electrolyte is accessible ) :If the
patient is hypokalemic on time of evaluation, start potassium replacement at the time of initial volume
expansion and before starting insulin therapy with bolus fluid, a concentration of 20 mmol/l should be
used.

o If the initial serum [K+] is 3 to 4.5 mmol: give after the bolus fluid and the child has passed
urine per L, 40 mEq per L of potassium .

o If the serum [K+] is 4.6 to 5.0, only 20 mEq per L of potassium should be added,

o if the [K+] is above 5.0, potassium should be withheld in the initial fluids.

o If less than 3 mmol per L after the initial bolus: upto K+ of 60 mEq per L or greater may be
necessary.

 NB: The maximum recommended rate of intravenous potassium replacement is usually 0.5
mmol/kg/h. and If hypokalemia persists despite a maximum rate of potassium replacement, then the
rate of insulin infusion can be reduced( decrease by half dose).

When IV fluids are unavailable ( in other setting not IN TASH ) , arrange urgent transport to a facility
that can provide IV fluid therapy. Give little sips (or small volumes through a syringe) of Oral
Rehydrating Solution (ORS) as frequently as possible (without the child vomiting). If vomiting does
not occur after 1-2 hours give ORS at a rate of 5 ml per kg body weight per hour. In some cases it
may be possible to insert a nasogastric tube and slowly rehydrate with ORS at 5 ml per kg body
weight per hour If ORS is not available, fruit juice and coconut water provide some potassium.If the
 child cannot be transported (e.g. roads blocked), give oral rehydration as above and SC insulin 0.05
units/kg every 1-2 hours..

4. Insulin therapy

Don’t start Insulin in the first hour of management! It should be started after an hour of fluid
resuscitation in order to steadily decrease the acidosis and it increases complication like shock, and
hypokalemia and cerebral edema
If there is IV fluid pump infuse( this is reserved for patients in pediatric intensive care with capacity
of frequent RBS and possible blood gas ) ) the child with 0.1 IU /kg / hour regular insulin you can
dilute 50 units regular insulin in 50 ml normal saline to make 1 Iu=1ml soln .Run 0.1IU /kg /hour
with a syringe per fuser .Before you connect to the cannula discard 5cc of it to avoid a lose in the
tubing . Iv insulin can drop the blood sugar fast so you have to make sure you have the capacity to
check random blood sugar every hourly a minimum .So we need to

In circumstances where continuous IV administration of insulin is not possible use hourly SC or IM

administration of a Regular insulin may be as effective as In infustion 0.1 iu /kg im /sc every hour (
recommended by ISPAD) . But for practical reasons in TASh give Subcutnous insulin dose: 0.5 unit/kg
every 6 hours give subcutaneous 6 hourly except the first dose ½ iv and ½ IM ( ths is extrapolation from
from ISPAD guidline was used and the first does IM route compared to Sc is used because the child is
dehydrated in the initial phase and it will not be observed from sc root )
Don’t omit insulin (If there is a rapid decline of glucose (100mg/hr) decrease the dose by 50% ~ to
keep RBS 11 mmol/l (200 mg/dl) until resolution of DKA ,do the RBS every one hour* if the
child is on continuous dose 0.1u/kg/hr you can decrease the dose to 0.05u/kg/hr but if the child is on
intermittent dose you can decrease the next dose by 50 % that is if the child is on 0.5 u/kg every 6
hourly when you get the child to be insulin sensitive you can decrease the next dose to 0.25 u/kg then
after 4-6 hours you can decide to continue with the decreased dose or to adjust to 0.5 u/kg

If Iv perfution is used IV insulin is metabolized rapidly, subcutaneous insulin must be given 30

minutes prior to the discontinuation of the infusion.

This continued until the blood glucose is less than 300 mg per dL and acidosis is correcting.

When the child become ketone free and clinically stable you can start the combination therapy with
lente and regular insulin based on their age on twice daily regimen).The initial dose of subcutaneous
insulin should be calculated based on a daily dose of 0. 5 0.75 Unit per kg per day in the prepubertal
child up to 1.0 Unit per kg per day in the pubertal child and beyond.

5.Treat complications
cerebral edema is the most important complication of DKA management the clinical symptom include
headache , and abnormal respiratory pattern. Other concerning signs are decrease or fluctuation in level of
consciousness , vomiting, headache, and bradycardia . If this signs appear give the child mannitol 1 g per kg
IV over 10 minute.The head of the bed 30 degrees and give oxygen and facilitate intubation should be
considered.

NB : rapid decling of RBS , excess fluid administration , rapid correction of PH with bicarbonate are
assocated . prevention is mandatory is very important .

6 .Address precipitating factor

The ears, throat, chest, and urine should be examined because infection is often a precipitating factor. Give
antibiotics to febrile patients after obtaining appropriate cultures of body fluids. Sometimes vaginal candidas,
tb , therefore through examination of every system is important .It could precipitating factor. precipitating
factor could also be , inadequate or insulin administration for a known DM patients, or emotional factors eg
puberty or family crises or exam at school

6. Monitoring
Close monitoring is very important , and a well-organized flow sheet ensures all parameters are being
observed look to Annex II . Vital sighn , input ,output , neurologic examination ( level of consciousness
Weight, assess the degree of dehydration, and lab results. The plasma glucose should be measured hourly
until the blood glucose is stable and less than 300 mg per dL, and as long as the child is on an insulin
infusion. Glucose measurement may be less frequent once the patient has been changed to subcutaneous
insulin.

Serum [K+] needs to be measured every 2 to 4 hours until the acidosis and hyperglycemia are normalized, or
more frequently if hypokalemia is encountered or bicarbonate therapy is used. Calcium, phosphate,
magnesium should be assessed initially and followed every 2 to 4 hours, more frequently if any are being
actively replaced. With the advent of point-of-care ketone measurements, it may be advisable to follow serum
ketone concentration every 2 to 4 hours. When the child is better hydrated and the acidosis resolves, mental
alertness will improve and symptoms of nausea, vomiting, and abdominal pain should remit. If they do not
resolve, an abdominal disorder should be considered

Transfer To Intensive care

Admission to an intensive care unit or specialized hospital referral is reirqed should be considered if the
patient is younger than 1 year of age, has sever DKA , present with shock , has a Glasgow Coma Scale score
of less than 12, has an initial measured [Na+] of more than 145 mmol per L, or has an initial [K+] of less than
3 mmol per L. or if the patient developes cerebral edema symptoms .
Mild Ketoacidosis
Hyperglycemia without ketoacidosis or with only mild acidosis. Generally, these admitted to the hospital for
the education purpose and stabilize or start insuline dose .Insulin therapy can be initiated subcutaneously, at a
total daily dose of 0.25 to 0.5 Unit per kg per day for the prepubertal child and 0.5 to 0.75 Unit per kg per day
for the adolescent. . In the conventional regimen, two-thirds of the total daily dose is administered in the
morning, and one-third before dinner; two-thirds of the morning dose and evening dose should be as an
Lente.

NB : don’t start insule which is not practical to administer eg 5.51 and 0.25 regular . look at the syring mark
Specific recommendations may vary with the age of the child and the experience of the family, but the
following scheme may be helpful. Oral intake should be about the same as would be given intravenously to
resolve the deficit and provide maintenance.

DKA patient management sheet

Name--------------------------------Age-----------Weight----------Date----------------

% of dehydration-----------------Resuscitation fluid-------------

Annex I
 FLOW SHEET

Date Time BP/hr PR/hr Temp/hr RBS/hr Urine Urine Neurologic Insulin Fluid Fluid
glucose/2hrs ketone status/hourly dose input/hr out
/2 rs 1hrl put/hr
for Iv
root
and 4-
hour
for sc