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peds.dka.v1

Pediatric diabetic ketoacidosis (DKA)

pediatricsacutepediatric
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm DKA criteria (BG >200 / 11.1 mmol/L + ketonemia/ketonuria + bicarbonate <18 OR pH <7.30); severity tier (mild pH 7.20-7.30 / moderate 7.10-7.20 / severe <7.10) (ISPAD 2022)

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Diagnosis confirmed + severity assigned

Patient inputs (18)

Age <5 yr is highest cerebral-edema risk; <2 yr → PICU (ISPAD 2022; Glaser 2001)

All fluid + insulin + electrolyte dosing weight-based (ISPAD 2022)

Baseline + serial — cerebral edema marker (ISPAD 2022)

Shock diagnosis (rare in DKA) (ISPAD 2022)

Tachycardia + dehydration; bradycardia + HTN = cerebral edema (ISPAD 2022)

Kussmaul respirations for compensation (ISPAD 2022)

Missed insulin / pump failure / new-onset / infection (ISPAD 2022)

BG >200 = DKA criterion (ISPAD 2022; ADA 2026 §16)

Ketonemia / ketonuria criterion (ISPAD 2022)

Severity tier (ISPAD 2022)

WBC often elevated even without infection (ISPAD 2022)

pCO2 <15 mmHg = cerebral edema risk (Glaser 2001)

New onset is highest cerebral-edema risk (ISPAD 2022; Glaser 2001)

K+ <3.5 hold insulin and replace; K+ >5.5 hold replacement (ISPAD 2022)

Pseudohyponatremia from hyperglycemia (corrected Na) (ISPAD 2022)

AKI marker; elevated BUN raises cerebral-edema risk (Glaser 2001)

Source if febrile precipitant (ISPAD 2022)

Replace if <1 (ISPAD 2022)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (11)

11 need judgement
  • informationallife_threateningcerebral_edema_features (ISPAD 2022)
    Severe HA, GCS decline, posturing, bradycardia + HTN, fixed pupil, irregular respirations, vomiting late (ISPAD 2022; Glaser 2001)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcerebral_edema_warning_signs
    Sub-overt cerebral-edema prodrome — emerging headache + bradycardia + HTN (Cushing's triad components) WITHOUT yet meeting overt GCS-drop / focal-neuro criteria; act NOW before overt features (ISPAD 2022; Glaser NEJM 2001 PMID 11172164)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_dka_pH_lt_7_10 (ISPAD 2022)
    pH <7.10 OR HCO3 <5 (ISPAD 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehypokalemia_at_presentation (ISPAD 2022)
    K+ <3.5 at presentation (ISPAD 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereshock_in_dka (ISPAD 2022)
    Hypotension + poor perfusion (uncommon in pediatric DKA) (ISPAD 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverenew_onset_t1d_high_cerebral_edema_risk (ISPAD 2022)
    New-onset T1D + age <5 + severe DKA (ISPAD 2022; Glaser 2001)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereinsulin_late_start
    Insulin infusion started CONCURRENT with fluid resuscitation OR before 1 h of fluid has been delivered (ISPAD 2024 update — insulin must start ≥ 1 h AFTER fluid resuscitation begins; concurrent start raises cerebral-edema risk)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebicarbonate_administered
    Sodium bicarbonate administered for DKA correction WITHOUT meeting the narrow rescue criteria (pH < 6.90 + hemodynamic compromise); bicarbonate is an INDEPENDENT cerebral-edema risk factor (Glaser 2001 OR 4.2, 95% CI 1.5-12.1; ISPAD 2022 strong recommendation against routine bicarbonate)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehypokalemia_below_3
    K+ < 3.0 mEq/L at presentation OR during treatment; extreme hypokalemia requires repletion to ≥ 3.5 BEFORE insulin start OR HOLD insulin if already running (ISPAD 2024 update; insulin drives K+ intracellular)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterapid_glucose_drop (ISPAD 2022)
    BG dropping >100 mg/dL/h (ISPAD 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateprecipitating_infection (ISPAD 2022)
    Febrile / source-positive at presentation (ISPAD 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

TREATMENToptionalDrives dose adjustment
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Recommended regimen

Pediatric DKA — ISPAD 2022 / PECARN-aligned
axis: peds_dka_acute
Selected axis "Pediatric DKA — ISPAD 2022 / PECARN-aligned" by default fallback (first axis)
  • insulin_regular_infusion
    first line
    short_acting_insulin
    0.05-0.1 U/kg/h IV; NO bolus • IV • continuous
    triggers: DKA_confirmed_K_>=3.5
    ISPAD 2022 — bolus not recommended; lower-dose 0.05 acceptable in mild DKA and <5 yr
    rxcui 253182
  • insulin_glargine
    first line
    long_acting_basal_insulin
    0.3 U/kg/day total daily dose split basal/prandial in new-onset; otherwise resume home dose • SC • once daily
    triggers: transition_when_ketones_cleared_and_eating
    Overlap with IV × 30-60 min before stopping infusion
    rxcui 274783
  • insulin_lispro
    first line
    rapid_acting_insulin
    0.05-0.1 U/kg with meals; correctional sliding scale • SC • with meals
    triggers: transition_eating
    Prandial coverage at transition
    rxcui 86009
  • normal saline / lactated Ringer's
    first line
    crystalloid_isotonic
    10 mL/kg over 1 h ONLY if shock (max 20 mL/kg); routine isotonic over 48 h replacing deficit + maintenance • IV • continuous
    triggers: DKA_initial_resuscitation
    PECARN FLUID — neither rate nor tonicity worsened cerebral edema risk; remain conservative; bolus restricted to shock
    rxcui 9863
  • potassium_chloride
    first line
    electrolyte
    Add 40 mEq/L if K+ 4-5; 60 mEq/L if K+ 3.5-4; hold if K+ >5.5 • IV • continuous
    triggers: K_below_5.5_after_first_void
    Insulin drives K+ intracellular; hypokalemia risk
    rxcui 8591
  • potassium_phosphate
    add on
    electrolyte
    Replace as 50/50 KCl + KPhos when phosphate <1 mg/dL • IV • continuous
    triggers: phosphate_lt_1_or_dysrhythmia
    Avoid hypocalcaemia from over-replacement
    rxcui 34322
  • mannitol
    rescue
    osmotic_diuretic
    0.5-1 g/kg IV over 20 min • IV • single dose, may repeat in 30 min
    triggers: cerebral_edema_features
    Cerebral edema rescue — alternative or adjunct to 3% saline
    rxcui 6628
  • hypertonic saline 3%
    rescue
    osmotic_agent
    5 mL/kg IV over 30 min • IV • single
    triggers: cerebral_edema_features
    Cerebral edema rescue — first-line at many centers
    rxcui 9863
  • sodium_bicarbonate
    rescue
    alkalinizing_agent
    1-2 mEq/kg IV over 1 h ONLY if pH <6.90 with hemodynamic compromise • IV • single
    triggers: pH_lt_6_90_with_hemodynamic_compromise
    Routine bicarbonate is harmful — increases cerebral edema risk
    rxcui 36676

outpatient playbook — drug actions (6)

  1. 1. basal insulin (glargine OR degludec OR detemir) — continuation
    rxcui 274783
    Discharge dose typically 0.3 U/kg/day TDD (new-onset) ÷ 50% basal; titrate by 10-20% q3-5d per CGM time-in-range OR fasting BG • SC • once daily (glargine, degludec) OR twice daily (detemir)
    trigger: Established T1D regimen at discharge
    ISPAD 2022 / ADA 2026 §16 — basal:bolus is foundation; titrate to time-in-range > 70% (CGM goal)
  2. 2. rapid-acting prandial insulin (lispro OR aspart OR glulisine)
    rxcui 86009
    0.05-0.1 U/kg with meals; ICR commonly 1:15 (younger child) to 1:8 (adolescent); correction 1 U per 50-100 mg/dL > target; titrate per CGM • SC • with meals + correction PRN
    trigger: Established prandial regimen at discharge
    ADA 2026 §16; titrate per CGM downloads
  3. 3. glucagon emergency kit (nasal OR injectable)
    rxcui 4832
    Nasal 3 mg intranasal OR injectable 0.5 mg (< 25 kg) OR 1 mg (≥ 25 kg) SC/IM/IV • IN OR SC/IM • PRN severe hypoglycemia
    trigger: Every T1D patient must have a current glucagon kit at home + school
    ADA 2026 §16 mandatory — verify family knows administration
  4. 4. CGM sensor + transmitter
    per device (Dexcom G7, FreeStyle Libre 3, Medtronic Guardian per insurance) • SC (sensor) • continuous; sensor change per device cycle
    trigger: T1D diagnosis — start at first follow-up if not started inpatient
    ADA 2026 §16 strong recommendation; reduces hypoglycemia + improves time-in-range
  5. 5. insulin pump consideration (if pump failure precipitant — re-evaluate; if new-onset — discuss after 3-6 mo MDI)
    per device + patient/family preference • SC • continuous infusion
    trigger: Patient/family interest + competence + insurance approval
    ISPAD 2022 pump consensus; not first-line in first 3-6 mo new-onset
  6. 6. metformin add-on (rare — only for adolescents with insulin resistance + obesity + T2DM-overlap features)
    rxcui 6809
    500-1000 mg BID with meals • PO • BID
    trigger: Adolescent T1D + BMI ≥ 85th percentile + insulin total daily dose > 1 U/kg/day
    ADA 2026 §16 conditional — not for typical pediatric T1D

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Polyuria, polydipsia, weight loss in a child (ISPAD 2022); Tachypnoea / Kussmaul breathing in known or suspected diabetic child (ISPAD 2022); Altered mental status in known or suspected diabetic child (ISPAD 2022).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Pediatric diabetic ketoacidosis (DKA)** (peds.dka.v1).
Phenotype framing: DKA vs HHS (pediatric HHS rare; T2DM + obesity), euglycemic DKA (SGLT2i adult), salicylate, methanol (ISPAD 2022)
Scope: Confirm DKA criteria (BG >200 / 11.1 mmol/L + ketonemia/ketonuria + bicarbonate <18 OR pH <7.30); severity tier (mild pH 7.20-7.30 / moderate 7.10-7.20 / severe <7.10) (ISPAD 2022)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Pediatric DKA — ISPAD 2022 / PECARN-aligned**.
1. insulin_regular_infusion 0.05-0.1 U/kg/h IV; NO bolus IV continuous (short_acting_insulin, first line) — ISPAD 2022 — bolus not recommended; lower-dose 0.05 acceptable in mild DKA and <5 yr
2. insulin_glargine 0.3 U/kg/day total daily dose split basal/prandial in new-onset; otherwise resume home dose SC once daily (long_acting_basal_insulin, first line) — Overlap with IV × 30-60 min before stopping infusion
3. insulin_lispro 0.05-0.1 U/kg with meals; correctional sliding scale SC with meals (rapid_acting_insulin, first line) — Prandial coverage at transition
4. normal saline / lactated Ringer's 10 mL/kg over 1 h ONLY if shock (max 20 mL/kg); routine isotonic over 48 h replacing deficit + maintenance IV continuous (crystalloid_isotonic, first line) — PECARN FLUID — neither rate nor tonicity worsened cerebral edema risk; remain conservative; bolus restricted to shock
5. potassium_chloride Add 40 mEq/L if K+ 4-5; 60 mEq/L if K+ 3.5-4; hold if K+ >5.5 IV continuous (electrolyte, first line) — Insulin drives K+ intracellular; hypokalemia risk
6. potassium_phosphate Replace as 50/50 KCl + KPhos when phosphate <1 mg/dL IV continuous (electrolyte, add on) — Avoid hypocalcaemia from over-replacement
7. mannitol 0.5-1 g/kg IV over 20 min IV single dose, may repeat in 30 min (osmotic_diuretic, rescue) — Cerebral edema rescue — alternative or adjunct to 3% saline
8. hypertonic saline 3% 5 mL/kg IV over 30 min IV single (osmotic_agent, rescue) — Cerebral edema rescue — first-line at many centers
9. sodium_bicarbonate 1-2 mEq/kg IV over 1 h ONLY if pH <6.90 with hemodynamic compromise IV single (alkalinizing_agent, rescue) — Routine bicarbonate is harmful — increases cerebral edema risk

Setting playbook (outpatient) — Post-DKA endocrine clinic follow-up — solidify insulin regimen, reinforce DSME + sick-day rules, start/continue CGM, address precipitant (pump training if pump failure), psychosocial screen for adherence, HbA1c at 3 mo, prevent recurrent DKA (ISPAD 2022 + ADA 2026 §16)
10. basal insulin (glargine OR degludec OR detemir) — continuation Discharge dose typically 0.3 U/kg/day TDD (new-onset) ÷ 50% basal; titrate by 10-20% q3-5d per CGM time-in-range OR fasting BG SC once daily (glargine, degludec) OR twice daily (detemir) — Established T1D regimen at discharge (ISPAD 2022 / ADA 2026 §16 — basal:bolus is foundation; titrate to time-in-range > 70% (CGM goal))
11. rapid-acting prandial insulin (lispro OR aspart OR glulisine) 0.05-0.1 U/kg with meals; ICR commonly 1:15 (younger child) to 1:8 (adolescent); correction 1 U per 50-100 mg/dL > target; titrate per CGM SC with meals + correction PRN — Established prandial regimen at discharge (ADA 2026 §16; titrate per CGM downloads)
12. glucagon emergency kit (nasal OR injectable) Nasal 3 mg intranasal OR injectable 0.5 mg (< 25 kg) OR 1 mg (≥ 25 kg) SC/IM/IV IN OR SC/IM PRN severe hypoglycemia — Every T1D patient must have a current glucagon kit at home + school (ADA 2026 §16 mandatory — verify family knows administration)
13. CGM sensor + transmitter per device (Dexcom G7, FreeStyle Libre 3, Medtronic Guardian per insurance) SC (sensor) continuous; sensor change per device cycle — T1D diagnosis — start at first follow-up if not started inpatient (ADA 2026 §16 strong recommendation; reduces hypoglycemia + improves time-in-range)
14. insulin pump consideration (if pump failure precipitant — re-evaluate; if new-onset — discuss after 3-6 mo MDI) per device + patient/family preference SC continuous infusion — Patient/family interest + competence + insurance approval (ISPAD 2022 pump consensus; not first-line in first 3-6 mo new-onset)
15. metformin add-on (rare — only for adolescents with insulin resistance + obesity + T2DM-overlap features) 500-1000 mg BID with meals PO BID — Adolescent T1D + BMI ≥ 85th percentile + insulin total daily dose > 1 U/kg/day (ADA 2026 §16 conditional — not for typical pediatric T1D)

Non-pharmacologic actions:
- Dietitian referral / continuation — carb counting reinforcement, balanced macros, hypo treatment with 15 g rapid carbs (ADA 2026 §16)
- Diabetes educator / CDCES follow-up — pump troubleshooting, CGM data review with family (ADA 2026 §16)
- Mental health referral if PHQ-9-A ≥ 10 OR diabetes distress elevated OR disordered eating screen positive (ADA 2026 §16)
- School plan — 504 / IEP update; nurse trained for emergency glucagon + BG management; classroom accommodations (ADA 2026 §16 school-care guidance)
- Family adherence support — caregiver education + chore-load assessment + identification of psychosocial barriers (ADA 2026 §16)
- Pump training session if pump returning or being initiated — supervised insertion, alarm response, BG monitoring frequency, ketone-check rules (ISPAD 2022)
- Sick-day rule reinforcement — never stop insulin (lower-dose basal continues), check ketones q2-4h if BG > 250 OR unwell, hydration, return-to-care criteria (ISPAD 2022)
- Driving / dating / college transition discussion if age ≥ 14 (ADA 2026 §16)

AVOID / contraindication checks:
- No insulin bolus in pediatric DKA (ISPAD 2022)
- No routine bicarbonate (ISPAD 2022)
- Bolus only if shock max 20mL per kg (ISPAD 2022; Kuppermann 2018)
- Hold K replacement if K above 5.5 (ISPAD 2022)
- Slow glucose correction le 100 mg/dL per h (ISPAD 2022)

Monitoring

Regimen monitoring:
- q1h vitals and neuro check (ISPAD 2022)
- q1h BG (ISPAD 2022)
- q2 to 4h iSTAT (ISPAD 2022)
- strict IO (ISPAD 2022)
- cerebral edema vigilance first 24h (ISPAD 2022; Glaser 2001)

Setting (outpatient) monitoring:
- Endocrine visit q3 mo minimum (ISPAD 2022; ADA 2026 §16)
- HbA1c q3 mo — target < 7.0% individualised (ADA 2026 §16 lowered from < 7.5% in 2023+)
- CGM download at every visit — time-in-range > 70%, time-below-range < 4%, GMI within 0.3% of HbA1c (ADA 2026 §16)
- BP every visit; lipid + microalbumin + dilated eye exam per annual screening schedule (ISPAD 2022 §screening)
- Thyroid + celiac annual screen (ISPAD 2022 §screening)
- Mental health rescreen annually OR more frequent if positive (ADA 2026 §16)
- Recurrent DKA flag — any episode prompts adherence + pump-function audit + psychosocial screen (ISPAD 2022)

Follow-up plan: Pediatric endocrinology, diabetes education, family sick-day rules + glucagon kit; annual screening (ADA 2026 §16; ISPAD 2022)
- Close-out criterion: Endocrine follow-up + family education complete

Monitoring phase: q1h vitals + neurochecks + BG; q2-4h iSTAT; strict I/O; cerebral edema vigilance (ISPAD 2022)

Disposition

Current setting: outpatient — Post-DKA endocrine clinic follow-up — solidify insulin regimen, reinforce DSME + sick-day rules, start/continue CGM, address precipitant (pump training if pump failure), psychosocial screen for adherence, HbA1c at 3 mo, prevent recurrent DKA (ISPAD 2022 + ADA 2026 §16)

Disposition criteria:
- Stable T1D management — HbA1c < 7.5% (individualised), time-in-range > 70%, no DKA in 12 mo, family demonstrating competence with regimen + sick-day rules, mental-health screens negative, age-appropriate transition planning underway (ISPAD 2022; ADA 2026 §16)

Escalation triggers (move to higher acuity):
- Recurrent DKA episode → ED + admit + adherence/psychosocial deep-dive (ISPAD 2022)
- HbA1c > 9% × 2 consecutive visits → intensify support, consider CGM/pump if not on; investigate adherence + psychosocial barriers (ADA 2026 §16)
- Severe hypoglycemia event (requiring assistance OR seizure OR LOC) → endo urgent visit + glucagon-kit verification + CGM low-alert audit (ADA 2026 §16)
- Disordered eating screen positive OR insulin omission for weight control → mental-health urgent referral (ADA 2026 §16; ISPAD 2022 disordered-eating consensus)
- School/home support breakdown → social work + extended family education (ADA 2026 §16)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Severe HA, GCS decline, posturing, bradycardia + HTN, fixed pupil, irregular respirations, vomiting late (ISPAD 2022; Glaser 2001)
- [LIFE_THREATENING] Sub-overt cerebral-edema prodrome — emerging headache + bradycardia + HTN (Cushing's triad components) WITHOUT yet meeting overt GCS-drop / focal-neuro criteria; act NOW before overt features (ISPAD 2022; Glaser NEJM 2001 PMID 11172164)
- [SEVERE] pH <7.10 OR HCO3 <5 (ISPAD 2022)

Citations

- ISPAD 2022 + 2024 update + PECARN FLUID NEJM 2018 + BSPED 2020 + Glaser NEJM 2001 (cerebral-edema risk model) [PMID:36537529](https://pubmed.ncbi.nlm.nih.gov/36537529/)
- Cited evidence (PMID 29899011) [PMID:29899011](https://pubmed.ncbi.nlm.nih.gov/29899011/)
- Cited evidence (PMID 29897851) [PMID:29897851](https://pubmed.ncbi.nlm.nih.gov/29897851/)
- Cited evidence (PMID 11138992) [PMID:11138992](https://pubmed.ncbi.nlm.nih.gov/11138992/)
- Cited evidence (PMID 11172164) [PMID:11172164](https://pubmed.ncbi.nlm.nih.gov/11172164/)

Last reconciled with current guidelines: 2026-05-14.
References