• Clinical assessment:
  
  • Airway, breathing, circulation
  • Degree of dehydration
  • Glasgow Coma Scale
• Insert two (2) intravenous cannulas in both antecubital fossa
  
  • Collect venous blood for pH, U&Es, LFTs, glucose, ketones, FBC, blood cultures
  • ?-hCG in women aged 15 – 50
  • Troponin, lipase if indicated
• Capillary blood ketones & glucose at triage and end of 1st hour

• 0.9% normal saline 1000ml given over 1 hour
• Repeat if systolic BP <100 mmHg after 1 hour (0.9% saline 1000 ml over 1 hour)

• Give intravenous potassium infusion before insulin if serum K+ is below 5 mmol/L.
• Run the potassium infusion in a sideline, so intravenous fluids are uninterrupted:
  

  Serum potassium	IV potassium
  <3.5mmol/L	2 x 10 mmol/L over 1 hour
  3.5 – 5 mmol/L	10 mmol/L over 1 hour
  >5 mmol/L	Nil potassium needed

• Commence insulin infusion when serum K+ >3.5mmol/L
• Run insulin infusion via a side-line, so the fluids are uninterrupted
• Hourly infusion rate = body weight ÷ 10
• Give usual dose of basal insulin (Lantus, Levemir or Toujeo) as well as the intravenous insulin infusion at the usual dose and time
• If the patient is on an insulin pump, remove this until the DKA is resolved

• Maintain airway
• Consider NGT if patient is vomiting
• If vomiting, keep patient nil by mouth or give ice to suck
• Assess GCS, neurological observations
• DVT prophylaxis
• Proton pump inhibitor to prevent gastritis

• 12-lead ECG
• Urine microscopy and sensitivities
• Chest x-ray
• Assess for sinusitis, cellulitis, dental infection etc.
• Lumbar puncture if indicated
• For newly diagnosed patients, collect venous blood for:
  
  • Anti-islet cell antibodies (anti-GAD antibodies, anti-IA2 antibodies and anti-ZnT8 antibodies)
  • Coeliac antibodies
  • TFTs

• ECG monitoring
• Maintain fluid balance chart
• 1 hourly capillary glucose
• 2nd hourly capillary ketones

• Clinical assessment:
  
  • Airway, breathing, circulation
  • Degree of dehydration
  • Glasgow Coma Scale
• Insert two (2) intravenous cannulas in both antecubital fossa
  
  • Collect venous blood for pH, U&Es, LFTs, glucose, ketones, FBC, blood cultures
  • ?-hCG in women aged 15 – 50
  • Troponin, lipase if indicated
• Capillary blood ketones & glucose at triage and end of 1st hour
• Insert IDC if patient is unconscious or unable to void on demand (very young children)

• If dehydrated, give 0.9% normal saline at 10 ml/kg over 1 hour
• If central capillary refill is >2 seconds, repeat IV bolus of 0.9% normal saline 10 ml/kg over 1 hour
• See Table 1 for initial fluid replacement in children with DKA

Table 1: Initial Fluid replacement for children with DKA (ml/hour)

• Take further history as to the trigger for DKA
  
  • Sepsis
  • Alcohol, illicit drugs
  • Missed insulin doses or pump failure
  • Medical illness eg. aMI, pancreatitis

• If systolic BP <100 mmHg:
  
  • Repeat intravenous bolus of 0.9% normal saline, 1L over 1 hour
• If systolic BP >100 mmHg:
  
  • Continue infusion of 0.9% normal saline
    
    1. 1L at 500ml/hour (2nd bag)
    2. 1L at 250ml/hour (3rd bag)
    3. 1L at 125ml/hour (4th & subsequent bags of 0.9% normal saline)

• Give intravenous potassium infusion if serum K+ is below 5 mmol/L:
  

  Serum potassium	IV potassium
  <3.5mmol/L	2 x 10 mmol/100 ml over 1 hour
  3.5 – 5 mmol/L	10 mmol/100 ml over 1 hour
  >5 mmol/L	Nil potassium needed

• Continue insulin infusion at 0.1units/kg per hour
• Continue this rate until capillary glucose <15 mmol/L
• When BGL falls to <15 mmol/L, change IV insulin to a sliding scale, aiming for glucose target 9-14 mmol/L:
  

  Blood glucose level	Infusion rate (units / hour)
  <4 mmol/L	Suspend infusion for 15 minutes until hypo treated
  4 – 8 mmol/L	0.5 units
  8.1 – 12 mmol/L	1 unit
  12.1 – 16 mmol/L	2 units
  16.1 – 20 mmol/L	3 units
  >20 mmol/L	4 units

• Give usual dose of basal insulin (Lantus, Levemir or Toujeo) as well as the intravenous insulin infusion at the usual dose and time

• DVT prophylaxis
• Proton pump inhibitor to prevent gastritis
• If patient is able to eat and drink, give:
  
  • Hydralyte ice blocks 1-2 per hour
  • Low GI carbohydrate eg. glass of milk, tub of yoghurt, 1-2 slices of toast or bread

• Age < 18 or >65 years
• Pregnant
• GCS <12
• Cardiac or renal failure
• Other serious comorbidities
• Hypokalaemia (<3.0mmol/L)
• Hyponatremia (<125 mmol/L)
  
  • Corrected [Na+] = [Na+] + (glucose -10)/3
• Systolic BP <90 mmHg
• PR <60 or >120 bpm
• Severe DKA
  
  • pH <7.1
  • HCO3 <5 mmol/L
  • Ketones >6 mmol/L

• Staff at local hospital unable to provide intensive monitoring
• Moderate - severe DKA
  
  • pH <7.2
  • HCO3 <8 mmol/L
  • Ketones >5 mmol/L

• ECG monitoring
• 1 hourly fluid balance chart
• 1 hourly capillary glucose
• 4th hourly capillary ketones
• Venous blood collection at 2 hours and 4 hours:
  
  • pH
  • potassium
  • Bicarbonate

Aim for:

• Glucose falling by 3 mmol/L per hour
• Bicarbonate increasing by 3 mmol/L per hour
• Ketones falling by 0.5mmol/L per hour

If these targets are not being achieved, increase the infusion rates of fluid and insulin

If patient is able to eat and drink, give:

• Hydralyte ice blocks 1-2 per hour
• Low GI carbohydrate eg. glass of milk, tub of yoghurt

• Sepsis
• Manage pain, nausea
• Manage medical triggers eg. aMI, CVA, pancreatitis
• Refer to diabetes educator if insulin pump is malfunctioning or insulin management needs review

• GCS and neurological assessment
• Assess level of hydration

• Continue 0.9% normal saline at initial
• Adjust infusion rate based on degree of dehydration

• Give intravenous potassium infusion if serum K+ is below 5 mmol/L:
  

  Serum potassium	IV potassium
  <3.5mmol/L	2 x 10 mmol/100 ml over 1 hour
  3.5 – 5 mmol/L	10 mmol/100 ml over 1 hour
  >5 mmol/L	Nil potassium needed

• Continue insulin infusion at 0.1units/kg per hour
• Continue this rate until capillary glucose <15 mmol/L
• When BGL falls to <15 mmol/L, change IV insulin to a sliding scale, aiming for glucose target 9-14 mmol/L:
  

  Blood glucose level	Infusion rate (units / hour)
  <4 mmol/L	Suspend infusion for 15 minutes until hypo treated
  4 – 8 mmol/L	0.5 units
  8.1 – 12 mmol/L	1 unit
  12.1 – 16 mmol/L	2 units
  16.1 – 20 mmol/L	3 units
  >20 mmol/L	4 units

• Give usual dose of basal insulin (Lantus, Levemir or Toujeo) as well as the intravenous insulin infusion at the usual dose and time

If patient is able to eat and drink, give:

• Hydralyte ice blocks 1-2 per hour
• Low GI carbohydrate
  eg. glass of milk, tub of yoghurt

Consider for transfer to a tertiary hospital:

• Age <2 years
• Decreased level of consciousness
• Seizures
• Severe acidosis pH <7.0
• Signs of cerebral oedema
• Cardiovascular compromise

Discuss with on-call Paediatric Endocrinologist at Lady Cilento Children’s Hospital

• Staff at local hospital unable to provide intensive monitoring
• Moderate - severe DKA
  
  • pH <7.2
  • HCO3 <8 mmol/L
  • Ketones >5 mmol/L

Discuss with on-call Paediatric Endocrinologist at Lady Cilento Children’s Hospital or closest tertiary hospital

• 1 hourly fluid balance chart
• 1 hourly capillary glucose
• 4th hourly capillary ketones
• Venous blood collection at 2 hours and 4 hours:
  
  • pH
  • potassium
  • Bicarbonate

Aim for:

• Glucose falling by 3 mmol/L per hour
• Bicarbonate increasing by 3 mmol/L per hour
• Ketones falling by 0.5mmol/L per hour

If these targets are not being achieved, increase the infusion rates of fluid and insulin

If patient is able to eat and drink, give:

• Hydralyte ice blocks 1-2 per hour
• Low GI carbohydrate eg. glass of milk, tub of yoghurt

• Sepsis
• New diagnosis
• Refer to diabetes educator to discuss insulin use and adherence

• State of hydration
• Level of consciousness
• State of underlying trigger for DKA eg. sepsis, aMI
• Ensure infusion lines are patent

• Continue infusion of 0.9% normal saline
  
  • 1L at 250ml/hour (3rd bag)
  • 1L at 125ml/hour (4th & all subsequent bags of 0.9% normal saline)
• Continue IV 0.9% normal saline @ 125 ml/h until patient is euvolemic

• Give intravenous potassium infusion if serum K+ is below 5 mmol/L:
  

  Serum potassium	IV potassium
  <3.5mmol/L	2 x 10 mmol/L over 1 hour
  3.5 – 5 mmol/L	10 mmol/L over 1 hour
  >5 mmol/L	Nil potassium needed

• Continue insulin infusion at 0.1units/kg per hour until capillary glucose <15 mmol/L
• When BGL falls to <15 mmol/L, change IV insulin to a sliding scale:
  

  Blood glucose level	Infusion rate (units / hour)
  <4 mmol/L	Suspend infusion for 15 minutes until hypo treated
  4 – 8 mmol/L	0.5 units
  8.1 – 12 mmol/L	1 unit
  12.1 – 16 mmol/L	2 units
  16.1 – 20 mmol/L	3 units
  >20 mmol/L	4 units

• Give usual dose of basal insulin (Lantus, Levemir or Toujeo) as well as the intravenous insulin infusion at the usual dose and time

• This runs in addition to the 0.9% Normal Saline and insulin infusion. Give it via Cannula 2
• Run IV 10% Dextrose at 100 ml/hour
• It switches off the ketosis and prevents hypoglycemia
• Continue until capillary ketones are <0.6mmol/l and patient is eating, drinking without vomiting

• DVT prophylaxis
• Proton pump inhibitor to prevent gastritis
• If patient is able to eat and drink, give:
  
  • Hydralyte ice blocks 1-2 per hour
  • Low GI carbohydrate eg. glass of milk, tub of yoghurt, 1-2 slices of toast or bread

• 1 hourly fluid balance chart
• 1 hourly capillary glucose
• 4th hourly capillary ketones
• Venous blood collection at 8 hours and 12 hours:
  
  • pH
  • potassium
  • Bicarbonate

Aim for:

• Glucose falling by 3 mmol/L per hour
• Bicarbonate increasing by 3 mmol/L per hour
• Ketones falling by 0.5mmol/L per hour

Targets are:

• Blood glucose levels 9 – 14 mmol/l
• Avoidance of hypoglycaemia (triggers DKA again)
• Bicarbonate >18 mmol/L
• Ketones <0.3mmol/L

If these targets are not being achieved, increase the infusion rates of fluid and insulin

If patient is able to eat and drink, give:

• Hydralyte ice blocks 1-2 per hour
• Low GI carbohydrate eg. glass of milk, tub of yoghurt

• Sepsis
• Manage pain, nausea
• Manage medical triggers eg. aMI, CVA, pancreatitis
• Refer to diabetes educator if insulin pump is malfunctioning or insulin management needs review

• State of hydration
• Level of consciousness
• State of underlying trigger for DKA eg. sepsis, aMI
• Ensure infusion lines are patent

• Continue 0.9% normal saline at initial
• Adjust infusion rate based on degree of dehydration
• If patient can eat and drink, give Hydralyte for rehydration, milk or yoghurt as tolerated

• Continue insulin infusion at 0.1units/kg per hour until capillary glucose <15 mmol/L
• When BGL falls to <15 mmol/L, change IV insulin to a sliding scale:
  

  Blood glucose level	Infusion rate (units / hour)
  <4 mmol/L	Suspend infusion for 15 minutes until hypo treated
  4 – 8 mmol/L	0.5 units
  8.1 – 12 mmol/L	1 unit
  12.1 – 16 mmol/L	2 units
  16.1 – 20 mmol/L	3 units
  >20 mmol/L	4 units

• Give usual dose of basal insulin (Lantus, Levemir or Toujeo) as well as the intravenous insulin infusion at the usual dose and time

• If patient is able to eat and drink, give Hydralyte ice blocks 1-2 per hour or low GI carbohydrate eg. glass of milk, tub of yoghurt

• 1 hourly fluid balance chart
• 1 hourly capillary glucose
• 4th hourly capillary ketones
• Venous blood collection at 8 hours and 12 hours:
  
  • pH
  • potassium
  • Bicarbonate

Aim for:

• Glucose falling by 3 mmol/L per hour
• Bicarbonate increasing by 3 mmol/L per hour
• Ketones falling by 0.5mmol/L per hour

Targets are:

• Blood glucose levels 9 – 14 mmol/l
• Avoidance of hypoglycaemia (triggers DKA again)
• Bicarbonate >18 mmol/L
• Ketones <0.3mmol/L

If these targets are not being achieved, increase the infusion rates of fluid and insulin

If patient is able to eat and drink, give:

• Hydralyte ice blocks 1-2 per hour
• Low GI carbohydrate eg. glass of milk, tub of yoghurt

• Sepsis
• Manage pain, nausea
• Missed insulin doses or pump malfunction
• New diagnosis of diabetes