Paediatric Diabetic Ketoacidosis NHI Patient Name Date

MONITORING

MAJOR RISK = CEREBRAL OEDEMA 1) Strict fluid balance (input / output) 4) Blood ketones (1-2 hrly if available)
Aim for slow metabolic correction over 48 hrs 5) Gas, Na, K, Cl (after 2hrs, then 2-4 hrly)
2) Hourly BP and vital signs and neurological observations
3) Hourly Blood Glucose 6) HDU /PICU if coma, pH<7.1, <2 yr

FLUID THERAPY Use 0.9% saline with 40mmol/l KCl for 1st 12 hrs
Weight Fluid Maintenance
1st 10 kg 4 ml/kg/hr Enter patient weight (kg) Maintenance rate (ml/hr) 0
2nd 10kg 2 ml/kg/hr Degree dehydration (%) 5 Maintenance volume over 48hrs (ml) 0
Every kg after 20kg 1 ml/kg/hr Total fluid bolus (ml) Rehydration volume over 48hrs (ml) 0
e.g. 25 kg => (4x10 + 2x10 + 1x5) ml/hr TOTAL (ML/HOUR) 0 Total fluid /48hrs (ml) minus fluid bolus 0
Neonates may need 100ml/kg/day
Monitor Coma Score
Corrected Na should rise by about 5 mmol/L in 1st
INSULIN (Only start infusion after 1st hr of fluid) CORRECTED NA 8 hours of therapy. If coma score falls and
corrected Na not rising assume cerebral oedema.
Sample1 Sample2
Add 50 units ActRapid* insulin to 50ml solution of 0.9% saline
(concentration 1 unit/ml, 0.1u/kg/hr = 0.1ml/kg/hr) Glucose (mmol/L) Give 5 mls/kg of 3% saline or mannitol 0.5-
Low corrected
1g/kg/dose andNanote
should rise during
response. Leveltherapy.
of If
Required insulin infusion rate (units/kg/hr) 0.1 Na (mmol/L) coma score falls
conciousness and corrected
should Na not
improve over rising
10-15 there
minutes
is a high risk of cerebral oedema.
Corrected Na
Run insulin infusion at 0.0 mls/hr #VALUE!

Carefully re-evaluate patient and refer to Section G

DO NOT REDUCE insulin rate until ketoacidosis improves Simplified Corrected Na formula of protocol.
If glucose falls (<17 mmol/L) add Glucose to IVI fluids. = plasma Na + 0.3x (Glu - 5.5)

* Can also use Novorapid, Humulog, or Humulin R

GLUCOSE CALCULATOR SERUM OSMOLALITY

500
Size Infusion bag(ml Sample1 Sample2
% Glucose at Start0 Glucose (mmol/L) 0 0 Monitor Osmolality
Osmolality should fall by no more than
% Glucose needed 7.5 Na (mmol/L) 0 0 1-2 mosmol/hr
75 K (mmol/L) If fall exceeds this, consider:
Remove 75.0 mls from bag and replace with 75.0 mls of 50% Glucose Serum Osmolality 0 0 1) slowing fluid deficit replacement
2) changing fluid to normal saline with 10%
0.0 dextrose

=2 x (Na + K) + Glu
Degree of DehydratioInsulin Infusion Rate Infusion Bag Size % Glucose at Start
3 0.05 500 0
5 0.1 1000 2.5
8 5
7.5
10