I. DEFINITION

A. Blood glucose usually >300 mg/dL

B. Serum bicarbonate <15 mEq/L or pH<7.30

II. EVALUATION

A. History

1. Polyuria, polydipsia

2. Estimated weight loss

3. Abdominal pain

4. Concurrent illness or infections, if any

5. Prescribed and missed insulin doses

6. Age < 5 years automatic ICU admission

7. Altered sensorium, headache

B. Physical Examination

1. Wt (actual), ht, m²

2. BP, T, HR, RR

3. Fruity breath

4. Kussmaul respiration

5. Neurological status - level of consciousness, fundal exam, pupils, Babinski reflex

C. Laboratory

1. Immediate at bedside:

a. Blood glucose by meter

2. Send to lab:

a. STAT: Na, K, HCO₃, Cl, glucose, BUN, Cr, lactate, β-hydroxybutyrate (BOHB)

b. Obtain pH.

c. HbA1c

d. New onset -- Diabetes Panel (Islet cell, insulin, and anti-GAD antibodies, C-peptide, insulin) AND celiac panel, thyroid peroxidase and thyroglobulin antibodies.

III. FLUIDS

A. Initial bolus: Lactated Ringers 10 mL/kg over 1 hr. and if clinically indicated, repeat only once. If frank shock, intervene as necessary.

B. Subsequent fluid: Administer 2.5 L/m²/day and never exceed 4 L/m²/day (including initial bolus) unless discussed w/Attending

If K£ 5.0, start 2 bag system to rapidly titrate dextrose:

Bag A: LR + KPO₄ 2mmol/100mL + KCL 1.5 mEq/

100 mL

Bag B: D10LR + KPO₄ 2mmol/100mL + KCL 1.5mEq/ 100 mL

Total IVF mL/hr = Bag A mL/hr + Bag B mL/hr

IV. INSULIN

For bicarb £ 15 mEq/L and pH < 7.2; and/or altered mental status should receive insulin drip. All others can receive subcutaneous insulin.

Insulin drip:

A. Preparation: Mix regular insulin, 100 units in 100 mL of NS (1 mL/hr = 1 unit/hr).

B. Dose: 0.1 units/kg/hr (0.05 units/kg/hr for age< 5y or hyperosmolar).

C. If acidosis persists, titrate insulin drip.

D. Titration: Titration of fluids (bag A&B) to maintain glucose between 100-200 mg/dl.

Subcutaneous insulin doses:

A. Basal insulin per home regimen or new onset regimen determined by Endocrine service (i.e. Lantus, NPH, or pump).

B. Novolog based on patient’s sensitivity factor (SF) subcut every 3 hr.

(current blood glucose – target blood glucose) = units Novolog

sensitivity factor

Endocrine service to determine SF.

C. Novolog for meals.

V. BICARBONATE

Should never be used unless there is evidence of cardiac failure.

VI. MONITOR

A. Airway & Breathing (cardiac monitor & pulse oximeter)

B. Insulin drip: Glucose q 1hr, electrolytes q 2 hr.x 2, then q. 4 hr. with improving anion gap. Check β-OHB, Ca, Phos, Magnesium q8hrs. Plot the real and corrected sodium (add 1.6 mEq Na for each 100 mg/dl of glucose above 100 mg/dl).

C. Subcutaneous insulin: Glucose every 3 hr, electrolytes q 3 hr x 2, then q 6 hr with improving anion gap (normal anion gap< 15). Check β-OHB, Ca, Phos, Magnesium q8hrs.

D. Neurological vital signs every hr for 12 hr on insulin drip or every 4 hr on subcut insulin.

E. Strict I/O

F. Consider Foley or NG tube if needed.

VII. DISPOSITION

A. Notify Endocrine/Diabetes service upon assessment of the patient.

B. Admit to the Intensive Care service, PICU, if an insulin infusion is required

C. Admit to Endocrine/Diabetes service, IMC, for management with diet and subcutaneous insulin (no insulin infusion is needed).

References:

1. European Society for Paediatric Endocrinology/Lawson Wilkins Pediatric Endocrine Consensus Statement on Diabetic Ketoacidosis in Children and Adolescents. Pediatrics 2004; 113(2): e133-e140.

2.Chase HP, Garg SK, Jelley DH. Diabetic ketoacidosis in children and the role of outpatient management. Pediatr Rev.1990; 11: 297 –304.

3. Poirier MP, Greer D, Satin-Smith M. A prospective study of the "two-bag system'' in diabetic ketoacidosis management. Clin Pediatr 2004; 43(9):809-

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