The International Society for Paediatric and Adolescent Diabetes (ISPAD) has published new comprehensive guidelines, including those for diabetic ketoacidosis.
Their summary:
• DKA is caused by either relative or absolute insulin deficiency.
• Children and adolescents with DKA should be managed in centers experienced in its treatment and where vital signs, neurological status and laboratory results can be monitored frequently
• Begin with fluid replacement before starting insulin therapy.
• Volume expansion (resuscitation) is required only if needed to restore peripheral circulation.
• Subsequent fluid administration (including oral fluids) should rehydrate evenly over 48 hours at a rate rarely in excess of 1.5 – 2 times the usual daily maintenance requirement.
• Begin with 0.1 U/kg/h. 1 – 2 hours AFTER starting fluid replacement therapy
• If the blood glucose concentration decreases too quickly or too low before DKA has resolved,
increase the amount of glucose administered. Do NOT decrease the insulin infusion
• Even with normal or high levels of serum potassium at presentation, there is always a total body deficit of potassium.
• Begin with 40 mmol potassium/L in the infusate or 20 mmol potassium/L in the patient receiving fluid at a rate >10 mL/kg/h.
• There is no evidence that bicarbonate is either necessary or safe in DKA.
• Have mannitol or hypertonic saline at the bedside and the dose to be given calculated beforehand.
• In case of profound neurological symptoms, mannitol should be given immediately.
• All cases of recurrent DKA are preventable.
Full guidelines available here
Other ISPAD guidelines available here