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Inpatient Survival Guide

CHLA Pediatric Endocrinology

Diabetic Ketoacidosis

DKA
Criteria
Inclusion — must meet all
  • Hyperglycemia with glucose ≥ 200 mg/dL
  • pH ≤ 7.30 or bicarbonate ≤ 18 mEq/L
  • Ketonemia (β-hydroxybutyrate ≥ 3 mmol/L) or ketonuria
Exclusion — any one
  • Hyperosmolar state:
    • Serum sodium ≥ 172 mEq/L, or
    • Glucose > 600 mg/dL
Initial Assessment
Shock Present
  • Fluids as needed for treatment of shock
No Shock
  • NS bolus 10–20 mL/kg over 30 min
  • Repeat as clinically indicated
  • Labs: VBG, Chem 14, Mg, Phos, UA
  • EKG if K+ > 6.5 mEq/L
  • Contact Endocrine Team
PICU Admission Criteria
Any one of the following
  • Venous pH < 7.05
  • Bicarbonate < 5 mEq/L
  • Mental status changes
  • Hypoglycemia after insulin initiation
  • Requirement for insulin infusion
  • Borderline conditions that may worsen clinically
Fluids & Insulin
Fluids
  • LR or D10LR
  • Rate = 1.5 × maintenance
  • Maximum rate: 500 mL/hr
Insulin
  • Infusion: 0.1 units/kg/hr
  • No insulin bolus
  • Lower rate may be needed for younger children or slower glucose drop
  • Insulin rate decisions made with Endocrine Team
Monitoring
  • POC blood glucose every hour
  • VBG and Chem 6: every 2 hours initially, then every 4 hours as improving
  • Neuro checks every 1–2 hours

If not improving or deteriorating: re-evaluate IVF calculations · adjust insulin · consider additional resuscitation · consider sepsis

Glucose-Based Fluid Adjustment
Blood Glucose (mg/dL) % Rate from LR % Rate from D10LR Final Dextrose
> 250100%0%0%
201–25050%50%5%
151–20025%75%7.5%
101–1500%100%10%
< 100Contact Endocrine — switch to D10W, stop insulin drip

Goal: limit glucose reduction to < 100 mg/dL/hr · If BG < 100 despite D10: restart insulin at 0.02 units/kg/hr below prior rate and contact Endocrine physician on call

Potassium Management
Serum K+ (mEq/L) Action
< 3.5Add 20 mEq/L K-acetate + 20 mEq/L KCl (total 40 mEq/L)
3.5–4.5Add 20 mEq/L K-acetate + 20 mEq/L KCl
4.6–5.5Add 20 mEq/L K-acetate + 20 mEq/L KCl
> 5.5Hold potassium — continue IVF without K, contact Endocrine Team
Neurologic Warning Signs
Monitor for any of the following
  • Headache
  • Slowing heart rate
  • Irritability
  • Decreased consciousness
  • Incontinence
  • Focal neurologic deficits
  • Any change in neurologic status

If present: exclude hypoglycemia → consider cerebral edema → if on SQ insulin, start insulin drip → escalate to PICU

Cerebral Edema Management
  • Elevate head of bed
  • Restrict IV fluids
  • Mannitol 1 g/kg IV over 20 minutes
  • OR 3% NaCl 5 mL/kg IV over 20 minutes
  • Notify Endocrine Team with updated status
  • Consider head CT after treatment
DKA Resolution Criteria
  • OK for chips once bicarbonate > 13 mEq/L and mental status normal
  • Serum bicarbonate ≥ 18 mEq/L
  • Clinically well, tolerating fluids
Transition to Subcutaneous Insulin
  • Contact Endocrine Team to review dosing and timing
  • See attached DKA Clinical Pathway (IP 2023)
  • Ensure overlap of IV insulin with first SQ dose
Clinical Assessment
Patient Data
mg/dL
mEq/L
mEq/L
mEq/L
mEq/L
mmol/L
Subcutaneous Insulin Calculator
New Onset Dosing Estimator
Weight
kg
TDD Factor
u/kg
Correction Target
mg/dL
Discharge — New Onset Diabetes
Specialty Pharmacy Checklist — Medi-Cal
  • Humalog KwikPen Rapid-acting insulin
  • Lantus Solostar Pen Basal insulin
  • Embecta Nano 4mm 32G Pen needles
  • Accu-Chek Softclix Lancets (100/box)
  • Accu-Chek Guide Glucose meter
  • Accu-Chek Guide Strips Test strips
  • Ketostix Reagent Strips Urine ketone strips (50/box)
  • Dexcom G7 Sensors CGM sensor
  • Dexcom G7 Receiver CGM receiver
  • Embecta Ultra-Fine 6mm 3/10 mL Syringes, half-unit scale
  • Isopropyl Alcohol 70% Alcohol swabs
  • Sharps Container