DKA NICE Guidline

Diabetic k
ketoacidosis
etoacidosis in children and yyoung
oung
people
NICE Pathways bring together everything NICE says on a topic in an interactive

flowchart. NICE Pathways are interactive and designed to be used online.
They are updated regularly as new NICE guidance is published. To view the latest
version of this NICE Pathway see:
http://pathways.nice.org.uk/pathways/diabetes-in-children-and-young-people
NICE Pathway last updated: 27 March 2018
This document contains a single flowchart and uses numbering to link the boxes to the
associated recommendations.
Diabetes in children and yyoung

oung people Page 1 of 13
© NICE 2018. All rights reserved. Subject to Notice of rights.
Diabetic k
ketoacidosis
oung people NICE Pathways

Diabetic k
ketoacidosis
1 Child or young person with diabetes
No additional information
2 Recognition, referral and diagnosis
Measure capillary blood glucose at presentation in children and young people without known
diabetes who have increased thirst, polyuria, recent unexplained weight loss or excessive
tiredness and any of the following:
nausea or vomiting
abdominal pain
hyperventilation
dehydration
reduced level of consciousness.
If the plasma glucose level is above 11 mmol/litre in a child or young person without known
diabetes, and they have symptoms that suggest diabetic ketoacidosis (DKA), suspect DKA and
immediately send them to a hospital with acute paediatric facilities.
Be aware that children and young people taking insulin for diabetes may develop DKA with
normal blood glucose levels.
Suspect DKA even if the blood glucose is normal in a child or young person with known
diabetes and any of following:
nausea or vomiting
abdominal pain
hyperventilation
dehydration
reduced level of consciousness.
When DKA is suspected in a child or young person with known diabetes measure the blood
ketones (beta-hydroxybutyrate), using a near-patient method if available. If the level is elevated,
immediately send them to a hospital with acute paediatric facilities.
When DKA is suspected in a child or young person with known diabetes and it is not possible to
measure the blood ketones (beta-hydroxybutyrate) using a near-patient method, immediately

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send them to a hospital with acute paediatric facilities.
If DKA is suspected or confirmed in a child or young person, explain to them and to their family
members or carers (as appropriate) that DKA is a serious matter that needs urgent hospital
assessment.
When a child or young person with suspected or known DKA arrives at hospital, measure their:
capillary blood glucose

capillary blood ketones (beta-hydroxybutyrate) if near-patient testing is available, or urine
ketones if it is not
capillary or venous pH and bicarbonate.
Diagnose DKA in children and young people with diabetes who have:
acidosis (indicated by blood pH below 7.3 or plasma bicarbonate below 18 mmol/litre) and
ketonaemia (indicated by blood beta-hydroxybutyrate above 3 mmol/litre) or ketonuria (++
and above on the standard strip marking scale).
Diagnose severe DKA in children and young people with DKA who have a blood pH below 7.1.
3 Initial management
Inform the responsible senior clinician once a diagnosis of DKA in a child or young person is
made.
Explain to the child or young person with DKA and to their family members or carers (as
appropriate) about their condition and the care that they may need.
When DKA is diagnosed in a child or young person in hospital, record their:
level of consciousness
vital signs (heart rate, blood pressure, temperature, respiratory rate [look for Kussmaul
breathing])
history of nausea or vomiting
clinical evidence of dehydration
body weight.
When DKA is diagnosed in a child or young person in hospital, measure and record the capillary
or venous:

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pH and pCO2
plasma sodium, potassium, urea and creatinine
plasma bicarbonate.
Consider a near-patient blood ketone (beta-hydroxybutyrate) testing method for rapid diagnosis
and monitoring of DKA in children and young people in hospital.
Children and young people with DKA should be cared for in a facility that can provide the level
of monitoring and care for DKA specified in these recommendations.
Children and young people with DKA should be cared for with one-to-one nursing either on a
high-dependency unit (preferably a paediatric unit), or on a general paediatric ward, if:
they are younger than 2 years or

they have severe DKA (indicated by a blood pH below 7.1).
Think about inserting a nasogastric tube if a child or young person with DKA has a reduced
level of consciousness and is vomiting, to reduce the risk of aspiration.
Seek urgent anaesthetic review and discuss with a paediatric critical care specialist if a child or
young person with DKA cannot protect their airway because they have a reduced level of
consciousness.
Discuss the use of inotropes with a paediatric critical care specialist if a child or young person
with DKA is in hypotensive shock.
Think about sepsis in a child or young person with DKA who has any of the following:
fever or hypothermia
hypotension
refractory acidosis
lactic acidosis.
See what NICE says on sepsis.
4 Fluid and insulin therapy
Treat DKA with oral fluids and subcutaneous insulin only if the child or young person is alert, not
nauseated or vomiting, and not clinically dehydrated.

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If DKA is treated with oral fluids and subcutaneous insulin, ensure that the child or young
person is recovering by monitoring for resolution of ketonaemia and acidosis.
Treat DKA with intravenous fluids and intravenous insulin if the child or young person is not
alert, is nauseated or vomiting or is clinically dehydrated.
Do not give oral fluids to a child or young person who is receiving intravenous fluids for DKA
unless ketosis is resolving, they are alert, and they are not nauseated or vomiting.
Do not give an intravenous fluid bolus to children and young people with mild or moderate DKA
(indicated by a blood pH of 7.1 or above).
Do not routinely give an intravenous fluid bolus to a child or young person with severe DKA
(indicated by a blood pH below 7.1).
Do not give more than one intravenous fluid bolus of 10 ml/kg 0.9% sodium chloride to a child or
young person with severe DKA (indicated by a blood pH below 7.1) without discussion with the
responsible senior paediatrician.
In children and young people with DKA, calculate their total fluid requirement for the first 48
hours by adding the estimated fluid deficit to the fluid maintenance requirement.
When calculating the fluid requirement for children and young people with DKA, assume:
a 5% fluid deficit in mild to moderate DKA (indicated by a blood pH of 7.1 or above)

a 10% fluid deficit in severe DKA (indicated by a blood pH below 7.1).
Calculate the maintenance fluid requirement for children and young people with DKA using the
following 'reduced volume' rules:
if they weigh less than 10 kg, give 2 ml/kg/hour

if they weigh between 10 and 40 kg, give 1 ml/kg/hour
if they weigh more than 40 kg, give a fixed volume of 40 ml/hour.
These are lower than standard fluid maintenance volumes because large fluid volumes are
associated with an increased risk of cerebral oedema.
Aim to replace the fluid deficit evenly over the first 48 hours in children and young people with
DKA, because faster rehydration is associated with an increased risk of cerebral oedema.
Use 0.9% sodium chloride without added glucose for both rehydration and maintenance fluid in

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children and young people with DKA until the plasma glucose concentration is below 14 mmol/
litre.
Ensure that all fluids (except any initial bolus) administered to children and young people with
DKA contain 40 mmol/litre potassium chloride, unless they have renal failure.
If more than 20 ml/kg of fluid has been given by intravenous bolus to a child or young person
with DKA, subtract any additional bolus volumes from the total fluid calculation for the 48-hour
period.
Do not give intravenous sodium bicarbonate to children and young people with DKA.
Think about inserting a urinary catheter if it is not possible to accurately measure urine output
for a child or young person with DKA.
Do not give children and young people with DKA additional intravenous fluid to replace urinary
losses.
Start an intravenous insulin infusion 1–2 hours after beginning intravenous fluid therapy in
children and young people with DKA.
When treating DKA with intravenous insulin in children and young people, use a soluble insulin
infusion at a dosage between 0.05 and 0.1 units/kg/hour. Do not give bolus doses of
intravenous insulin.
If a child or young person with DKA is using insulin pump therapy, disconnect the pump when
starting intravenous insulin therapy.
In discussion with a diabetes specialist, think about continuing subcutaneous basal insulin in a
child or young person who was using a basal insulin before the onset of DKA.
Change fluids to 0.9% sodium chloride with 5% glucose and 40 mmol/litre potassium chloride
once the plasma glucose concentration falls below 14 mmol/litre in children and young people
with DKA.
If during treatment for DKA a child or young person's plasma glucose falls below 6 mmol/litre:
increase the glucose concentration of the intravenous fluid infusion, and

if there is persisting ketosis, continue to give insulin at a dosage of least 0.05 units/kg/hour.
If the blood beta-hydroxybutyrate level is not falling within 6–8 hours in a child or young person

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with DKA, think about increasing the insulin dosage to 0.1 units/kg/hour or greater.
Think about stopping intravenous fluid therapy for DKA in a child or young person if ketosis is
resolving, they are alert, and they can take oral fluids without nausea or vomiting.
Do not change from intravenous insulin to subcutaneous insulin in a child or young person with
DKA until ketosis is resolving, they are alert, and they can take oral fluids without nausea or
vomiting.
Start subcutaneous insulin in a child or young person with DKA at least 30 minutes before
stopping intravenous insulin.
For a child or young person with DKA who is using insulin pump therapy, restart the pump at
least 60 minutes before stopping intravenous insulin. Change the insulin cartridge and infusion
set, and insert the cannula into a new subcutaneous site.
See what NICE says on intravenous fluid therapy in hospital.
5 Monitoring during therapy
Monitor and record the following at least hourly in children and young people with DKA:
capillary blood glucose

vital signs (heart rate, blood pressure, temperature, respiratory rate [look for Kussmaul
breathing])
fluid balance, with fluid input and output charts
level of consciousness (using the modified Glasgow coma scale).
Monitor and record the level of consciousness (using the modified Glasgow coma scale) and
the heart rate (to detect bradycardia) every 30 minutes in:
children under 2 years with DKA

children and young people with severe DKA (indicated by a blood pH below 7.1).
This is because these children and young people are at increased risk of cerebral oedema.
Monitor children and young people receiving intravenous therapy for DKA using continuous
electrocardiogram (ECG) to detect signs of hypokalaemia, including ST-segment depression
and prominent U-waves.

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Ensure that healthcare professionals performing the monitoring described above know what to
look for and when to seek advice.
At 2 hours after starting treatment, and then at least every 4 hours, carry out and record the
results of the following blood tests in children and young people with DKA:
glucose (laboratory measurement)

blood pH and pCO2
plasma sodium, potassium and urea
beta-hydroxybutyrate.
A doctor involved in the care of the child or young person with DKA should review them face-to-
face at diagnosis and then at least every 4 hours, and more frequently if:
they are aged under 2 years

they have severe DKA (indicated by a blood pH below 7.1)
there are any other reasons for special concern.
At each face-to-face review of children and young people with DKA, assess the following:
clinical status, including vital signs and neurological status

results of blood investigations
ECG trace
cumulative fluid balance record.
Update the child and young person with DKA and their family members or carers (as
appropriate) regularly about their progress.
6 Complications
Cerebral oedema
Immediately assess children and young people with DKA for suspected cerebral oedema if they
have any of these early manifestations:
headache
agitation or irritability
unexpected fall in heart rate
increased blood pressure.

Diabetic k
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If cerebral oedema is suspected in a child or young person with DKA, treat immediately with the
most readily available of mannitol (20%, 0.5–1 g/kg over 10–15 minutes) or hypertonic sodium
chloride (2.7% or 3%, 2.5–5 ml/kg over 10–15 minutes).
Immediately treat for cerebral oedema using the most readily available of mannitol (20%, 0.5–1
g/kg over 10–15 minutes) or hypertonic sodium chloride (2.7% or 3%, 2.5–5 ml/kg over 10–15
minutes) if a child or young person with DKA develops any of these signs:
deterioration in level of consciousness

abnormalities of breathing pattern, for example respiratory pauses
oculomotor palsies
pupillary inequality or dilatation.
After starting treatment for cerebral oedema with mannitol or hypertonic sodium chloride in a
child or young person with DKA, immediately seek specialist advice on further management,
including which care setting would be best.
Hypokalaemia
If a child or young person with DKA develops hypokalaemia (potassium below 3 mmol/litre):
think about temporarily suspending the insulin infusion

discuss hypokalaemia management urgently with a paediatric critical care specialist,
because a central venous catheter is needed for intravenous administration of potassium
solutions above 40 mmol/litre.
Venous thromboembolic disease
Be aware of the increased risk of venous thromboembolism in children and young people with
DKA, especially those with central venous catheters.
See what NICE says on venous thromboembolism.
7 Avoiding future episodes
After a child or young person with known diabetes has recovered from an episode of DKA,
discuss with them and their family members or carers (if appropriate) the factors that may have
led to the episode.
Think about the possibility of non-adherence to therapy in children and young people with

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established type 1 diabetes who present with DKA, especially if the DKA is recurrent.
Advise children and young people who have had an episode of DKA and their family members
or carers (if appropriate) how to reduce the risk of future episodes. In particular, advise them of
the importance of managing intercurrent illnesses.
8 Type 1 diabetes
See Diabetes in children and young people / Type 1 diabetes in children and young people
9 Type 2 diabetes
See Diabetes in children and young people / Type 2 diabetes in children and young people

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Sources
Diabetes (type 1 and type 2) in children and young people: diagnosis and management (2015)
NICE guideline NG18
Your responsibility
Guidelines
The recommendations in this guideline represent the view of NICE, arrived at after careful
consideration of the evidence available. When exercising their judgement, professionals and
practitioners are expected to take this guideline fully into account, alongside the individual
needs, preferences and values of their patients or the people using their service. It is not
mandatory to apply the recommendations, and the guideline does not override the responsibility
to make decisions appropriate to the circumstances of the individual, in consultation with them
and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline
to be applied when individual professionals and people using services wish to use it. They
should do so in the context of local and national priorities for funding and developing services,
and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to
advance equality of opportunity and to reduce health inequalities. Nothing in this guideline
should be interpreted in a way that would be inconsistent with complying with those duties.
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health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.
Technology appraisals
The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, health
professionals are expected to take these recommendations fully into account, alongside the
individual needs, preferences and values of their patients. The application of the

Diabetic k
ketoacidosis
recommendations in this interactive flowchart is at the discretion of health professionals and

their individual patients and do not override the responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable
the recommendations to be applied when individual health professionals and their patients wish
to use it, in accordance with the NHS Constitution. They should do so in light of their duties to
have due regard to the need to eliminate unlawful discrimination, to advance equality of
opportunity and to reduce health inequalities.

Medical technologies guidance, diagnostics guidance and interventional procedures

guidance
The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, healthcare
professionals are expected to take these recommendations fully into account. However, the
interactive flowchart does not override the individual responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in

their local context, in light of their duties to have due regard to the need to eliminate unlawful
discrimination, advance equality of opportunity, and foster good relations. Nothing in this
interactive flowchart should be interpreted in a way that would be inconsistent with compliance
with those duties.



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Diabetic k

NICE Pathways bring together everything NICE says on a topic in an interactive

Diabetes in children and yyoung

Diabetes in children and yyoung

1 Child or young person with diabetes

2 Recognition, referral and diagnosis

Diabetes in children and yyoung

send them to a hospital with acute paediatric facilities.

capillary blood glucose

When DKA is diagnosed in a child or young person in hospital, record their:

Diabetes in children and yyoung

they are younger than 2 years or

See what NICE says on sepsis.

4 Fluid and insulin therapy

Diabetes in children and yyoung

a 5% fluid deficit in mild to moderate DKA (indicated by a blood pH of 7.1 or above)

if they weigh less than 10 kg, give 2 ml/kg/hour

Diabetes in children and yyoung

increase the glucose concentration of the intravenous fluid infusion, and

Diabetes in children and yyoung

See what NICE says on intravenous fluid therapy in hospital.

5 Monitoring during therapy

capillary blood glucose

children under 2 years with DKA

Diabetes in children and yyoung

glucose (laboratory measurement)

they are aged under 2 years

clinical status, including vital signs and neurological status

Diabetes in children and yyoung

deterioration in level of consciousness

think about temporarily suspending the insulin infusion

See what NICE says on venous thromboembolism.

7 Avoiding future episodes

Diabetes in children and yyoung

Diabetes in children and yyoung

Commissioners and providers have a responsibility to promote an environmentally sustainable

Diabetes in children and yyoung

recommendations in this interactive flowchart is at the discretion of health professionals and

Commissioners and providers have a responsibility to promote an environmentally sustainable

Medical technologies guidance, diagnostics guidance and interventional procedures

Commissioners and/or providers have a responsibility to implement the recommendations, in

Commissioners and providers have a responsibility to promote an environmentally sustainable

Diabetes in children and yyoung

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