Synopsis
Diagnose and grade childhood diabetic ketoacidosis, restore circulation and correct dehydration and ketosis using the current BSPED protocol, while detecting and treating cerebral injury immediately without waiting for neuroimaging.
- Paediatric DKA requires hyperglycaemia, significant ketonaemia or ketonuria and metabolic acidosis; blood beta-hydroxybutyrate and venous pH are more useful for serial treatment than urine ketones alone.
- Use ABCDE, weigh the child, establish neurological baseline and obtain senior paediatric and critical-care support early; record every fluid already received.
- True shock means impaired central circulation, weak pulses and hypotension, not cool hands alone. Give isotonic crystalloid in 10 ml/kg boluses over 15 minutes with reassessment, up to 40 ml/kg before considering inotropes.
- A non-shocked child needing intravenous treatment receives 0.9% sodium chloride 10 ml/kg over 30 minutes, then calculated maintenance plus deficit replacement generally over 48 hours under BSPED.
- Start soluble insulin infusion 0.05 to 0.1 units/kg/hour one to two hours after fluids begin; 0.05 units/kg/hour is usually sufficient, especially under 5 years, and no insulin bolus is given.
- Add potassium to ongoing fluids as directed unless hyperkalaemia or absent urine makes it unsafe; serum potassium can be high despite severe total-body depletion.
- When glucose reaches 14 mmol/L, add 5% glucose to 0.9% sodium chloride and continue insulin to clear ketones; increase glucose concentration if needed rather than stopping insulin prematurely.
- Monitor hourly observations, neurological state, glucose and fluid balance, with at least two-hourly ketones, electrolytes and venous acid-base testing initially according to severity and protocol.
- Headache, irritability, falling consciousness, unexpected bradycardia, rising blood pressure, abnormal breathing, cranial-nerve signs or posturing means suspected cerebral injury.
- Treat suspected cerebral oedema immediately with available hypertonic saline 2.7% or 3% 2.5 to 5 ml/kg over 10 to 15 minutes, or mannitol 20% 0.5 to 1 g/kg over 10 to 15 minutes; do not wait for CT.
Key red flags
Any neurological change during DKA is cerebral injury until urgently assessed and treated.
Hypotension, weak central pulses or deteriorating perfusion requires controlled shock resuscitation and critical-care involvement.
Potassium below 3.0 mmol/L during insulin therapy creates immediate arrhythmia risk and needs urgent specialist correction.
A glucose fall without ketone clearance is not recovery and must not prompt premature insulin cessation.
Falling measured sodium as glucose declines can indicate an adverse water shift and requires senior review of fluid calculations.
Persistent vomiting, worsening abdominal signs or lactate despite metabolic improvement suggests an additional diagnosis.
Recurrent DKA or an unexplained delay in presentation requires psychosocial, access and safeguarding assessment.
Reduced consciousness, abnormal respiration, pupil change, cranial palsy or posturing requires immediate cerebral-oedema treatment.
Investigation priorities
Confirm the biochemical triad, grade acidosis and establish serial markers before treatment alters them.
Management branches
A child has hyperglycaemia, ketones and suspected acidosis or impaired perfusion.
- Use ABCDE, weigh, record neurological status and fluids, obtain IV access and send glucose, ketones, venous gas, electrolytes and renal tests.
- For shock give isotonic crystalloid 10 ml/kg over 15 minutes, reassess and repeat when needed up to 40 ml/kg with critical-care input.
- For a non-shocked child requiring IV therapy give 0.9% sodium chloride 10 ml/kg over 30 minutes and calculate the BSPED 48-hour plan.