Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX
Diabetic ketoacidosis (DKA) is a medical emergency that requires prompt management with close monitoring and careful correction of fluid and electrolyte imbalances, often necessitating hospital admission NICE CKS,NICE CKS.
Initiating Fluid Replacement Therapy:
- For patients with DKA who are not alert, are nauseated or vomiting, or are clinically dehydrated, intravenous fluids should be used NICE NG18. Oral fluids should not be given if the patient is receiving intravenous fluids for DKA, unless ketosis is resolving, they are alert, and not nauseated or vomiting NICE NG18.
- For clinically dehydrated patients not in shock, give an initial intravenous bolus of 10 ml/kg 0.9% sodium chloride over 30 minutes NICE NG18. A second 10 ml/kg bolus of 0.9% sodium chloride should only be considered if needed to improve tissue perfusion after reassessment, and discussion with a senior paediatrician is required before giving more than one bolus NICE NG18.
- For patients showing signs of shock (weak, thready pulse and hypotension), an initial intravenous bolus of 10 ml/kg 0.9% sodium chloride should be given as soon as possible NICE NG18.
- The total fluid requirement for the first 48 hours is calculated by adding the estimated fluid deficit to the fluid maintenance requirement NICE NG18. For mild-to-moderate DKA (blood pH 7.1 or above), assume 5% dehydration; for severe DKA (blood pH below 7.1), assume 10% dehydration NICE NG18. The deficit should be replaced evenly over the first 48 hours NICE NG18. The Holliday–Segar formula is used for maintenance: 100 ml/kg for the first 10 kg, 50 ml/kg for the second 10 kg, and 20 ml/kg for every kg thereafter, with a maximum weight of 75 kg in the calculation NICE NG18. Any initial bolus volumes should be subtracted from the total fluid deficit, unless the patient is in shock NICE NG18.
- Use 0.9% sodium chloride without added glucose for both rehydration and maintenance until the plasma glucose concentration is below 14 mmol/litre NICE NG18.
- Include 40 mmol/litre (or 20 mmol/500 ml) potassium chloride in all fluids (except initial boluses), unless the patient has anuria or their potassium level is above the normal range NICE NG18. Do not delay potassium replacement, as hypokalaemia can occur once insulin infusion starts NICE NG18. If potassium levels are above normal, only add potassium chloride if potassium is less than 5.5 mmol/litre or they have a history of passing urine NICE NG18. For patients with hypokalaemia at presentation, include potassium chloride in intravenous fluids before starting the insulin infusion NICE NG18.
- Monitor sodium levels throughout DKA treatment and calculate corrected sodium initially to identify hyponatraemia NICE NG18. Be aware that falling serum sodium can indicate possible cerebral oedema, while a rapid and ongoing rise may also be a sign of cerebral oedema NICE NG18.
Monitoring Requirements:
- At least hourly: Monitor and record capillary blood glucose, heart rate, blood pressure, temperature, respiratory rate (checking for Kussmaul breathing), fluid balance (input and output charts), and level of consciousness (using modified Glasgow Coma Scale) NICE NG18.
- Every 30 minutes: For children under 2 years or those with severe DKA (blood pH below 7.1), monitor and record level of consciousness (modified Glasgow Coma Scale) and heart rate (to detect bradycardia) due to increased risk of cerebral oedema NICE NG18.
- Continuous ECG: Monitor for signs of hypokalaemia (e.g., ST-segment depression, prominent U-waves) NICE NG18.
- Blood tests: At 2 hours after starting treatment, and then at least every 4 hours, carry out and record laboratory measurements of glucose, blood pH and pCO2, plasma sodium, potassium, urea, and beta-hydroxybutyrate NICE NG18.
- Doctor review: A doctor involved in the patient's care should review them face-to-face at diagnosis and then at least every 4 hours, or more frequently if they are under 2 years, have severe DKA, or other concerns NICE NG18. During review, assess clinical status (vital signs, neurological status), blood investigation results, ECG trace, and cumulative fluid balance record NICE NG18.
- Cerebral Oedema: Immediately assess for suspected cerebral oedema if there are early manifestations such as headache, agitation/irritability, unexpected fall in heart rate, or increased blood pressure NICE NG18. Start treatment immediately if cerebral oedema is suspected or if signs like deterioration in consciousness, abnormal breathing patterns, oculomotor palsies, or pupillary inequality/dilatation are present NICE NG18.
- Ensure healthcare professionals performing monitoring know what to look for and when to seek advice NICE NG18.