Pediatric Diabetic Ketoacidosis (DKA) — Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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1. [Decision] Signs of cerebral edema?
   Pediatric DKA — any signs of cerebral edema? (Pediatric DKA: hyperglycemia + ketosis + metabolic acidosis. Cerebral edema is the most feared complication (more common in children, ~25% mortality, can occur before treatment), risk = young age/new-onset/severe acidosis/rapid osmolar shifts. Monitor: headache, declining consciousness, bradycardia + hypertension, abnormal breathing.)
   • Signs of cerebral edema present → Cerebral edema → treat immediately
   • No cerebral edema, standard treatment → Standard treatment
2. [End] Standard treatment
   1) Fluids — isotonic saline 10–20 mL/kg over 30 min to correct shock, then replace the deficit over ~24–48 h. 2) Insulin started only after 1 h of fluids, no bolus, 0.05–0.1 U/kg/h (start only once K >3.0; if ≤3.0 give potassium first). 3) When glucose falls to 14–17 mmol/L add dextrose to maintain and continue insulin to clear ketones. 4) Early potassium, anticipate phosphate; avoid bicarbonate. 5) Continuous monitoring of neuro status, glucose, electrolytes, blood gas.
3. [End] Cerebral edema → treat immediately
   Signs of cerebral edema (headache/declining consciousness/bradycardia + hypertension/abnormal breathing): treat immediately, do not delay for imaging — hypertonic saline (3%) or mannitol, elevate the head of the bed, slow the fluid rate, protect the airway; head CT once stable. Pediatric ICU, endocrinology consult.

Source guidelines & references

• ISPAD / Canadian Paediatric Society management of pediatric DKA

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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