DKA is defined by: ketonemia, hyperglycemia, pH < 7.3 (H+ > 51), HCO3 < 15 mmol/L
corrected Na+ = ((glucose-5.5)/2) + Na+
- usually 10% dehydrated
- 0.9% saline at 10-20 mL/kg over 1 hour
- use 0.45% saline
- rate=maintenance + remaining deficit replaced evenly over 24-48 hrs (if the corrected Na+ > 145 then replace over 48 hours (i.e. slowly))
- replace urine losses if glucose > 20 mmol/L
- if corrected Na+ falls, change to 0.9% NS and decrease the rate
- once glucose is 15 mmol/L change IV to D5-0.45% saline
- start after first hour of saline infusion (repeat glucose)
- use 0.1 units/kg of Regular or Toronto insulin IV push
- infuse 0.1 units/kg/hr (mix 50 units in 500 mL of 0.9% NS , rate = 0.1 mL/kg/hr)
- when serum HCO3 > 15 mmol/L decrease the rate to 0.05 units/kg/hr
- aim to keep the serum glucose between 8 and 15 mml/L (you may need to add extra dextrose to the fluid replacement solution rather than stopping the insulin)
- continue the insulin infusion until the acidosis is resolved (HCO3 is normal)
- fall in blood glucose should not exceed 5-6 mmol/L/hr (you may need to increase the glucose in the fluid replacement solution, slow the rate of the insulin infusion, or slow the IV replacement solution rate)
Potassium
- shifts to ICF with insulin, a total body deficit
- add 40 mmol/L IV fluid
- 1/2 as KCl and the other half as phosphate
- if calcium is low, give as KCl
Phosphate
- as above
- may cause hypocalcemia
- of theoretical benefit
Bicarbonate
- avoid if possible
- consider only in severe, unstable patients with a pH < 7.0 (e.g. arrhythmia’s)
- infuse 1 mmol/kg over 1 hr - only correct to 7.2
Monitoring
- vitals and neurovitals q1-2h
- glucose q1h
- cap gas, electrolytes q4h
- calcium and phosphate q8h (especially if running phosphate)
Dr.
Couch
Pediatric Endocrinology
Department of Pediatrics
University of Alberta
Revised: July 08, 1997