Question :
Posted On : 29 Nov 2015
may you provide me with the latest guidelines to manage DKA
many thanks
Expert Answer :
The latest guidelines issued by the British Society for Pediatric Endocrinology and Diabetes {BSPED}, in 2009 are:

a} Volume of fluid -
If in shock, give a 10 ml, kg 0.9 percent saline {maximum of 30 ml, kg} over 30 mins. Once circulating blood volume has been restored, calculate fluid requirements as follows

Requirement = Maintenance plus Deficit – bolus
Deficit {litres} = percent dehydration x body weight {kg}, convert to ml
Use 5 percent to 8 percent dehydration to calculate fluids.

Maintenance requirements:
Weight 0 – 12.9 kg 80 ml, kg, 24 hrs
13 – 19.9 kg 65 ml, kg, 24 hrs

Give total volume over the next 48 hours.
Howebsitey rate = {48 hr maintenance plus deficit – bolus}, 48hr

b} Type of fluid -
Initially use 0.9 percent saline with 20 mmol KCl in 500ml {unless patient is anuric}, continue for at least 12 hours.
Once blood Glucose has fallen to 14 mmol, l add Glucose to the fluid.

After 12 hours, if the plasma sodium level is stable or increasing, change to 0.45 percent saline.
If the plasma sodium is falling, continue with Normal Saline {with or without Glucose depending on blood Glucose levels}.
Check blood glucose, pH, electrolytes, urine ketones 2 hrly initially, then 4 hrly.

c} Oral Fluids :

In severe dehydration, impaired consciousness and acidosis do not allow fluids by mouth. Put N, G tube.

Oral fluids should only be given after good clinical improvement and no vomiting

After resuscitation, potassium should be added immediately unless anuria is suspected. Levels in the blood will fall once Insulin is started.
Monitor ECG changes

3. Insulin :
There is some evidence that cerebral oedema is more likely if Insulin is started early. Therefore DO NOT start Insulin until intravenous fluids have been running for at least an hour.
Continuous low-dose intravenous infusion is the preferred method. at 0.1 units, kg, hour {0.1ml, kg, hour} of human soluble insulin.

Once the blood Glucose level falls to 14mmol, l, change the fluid to contain 5 percent glucose. The Insulin dose needs to be maintained at 0.1 units, kg, hour to switch off ketogenesis.

If the blood Glucose falls below 4 mmol, l, give a bolus of 2 ml, kg of 10 percent Glucose and increase the Glucose concentration of the infusion. Insulin can temporarily be reduced for 1 hour.

Once the pH is above 7.3, the blood Glucose is down to 14 mmol, l, and a glucose-containing fluid has been started, consider reducing the Insulin infusion rate, but to no less than 0.05 units, kg, hour.

Bicarbonate should only be used if pH Less than 6.9 and shock. Its only purpose is to improve cardiac contractility in severe shock.

no evidence that replacement has any clinical benefit
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