The BC Children's Hospital diabetic ketoacidosis (DKA) protocol has now been revised.
Following the publication of the
PEKARN DKA FLUID Trial [New Engl J Med 2018;378(24):2275–2287], which demonstrated the safety of more-aggressive fluid replacement regimens than are used in current DKA protocols, the Division of Pediatric Endocrinology & Diabetes has updated the BCCH DKA Protocol. Our 2024 revision aligns closely with the
DKA protocol developed by
TREKK (Translating Emergency Knowledge for Kids), which is designed for the initial management of pediatric DKA in most Canadian emergency departments, as well as with the
DKA algorithm developed by the
Canadian Pediatric Endocrine Group, which is designed for ongoing inpatient management of DKA. The 2024 revision is also aligned with the
Clinical Practice Consensus Guidelines 2022 of the
International Society for Pediatric and Adolescent Diabetes (ISPAD).
The protocol and accompanying documents can be downloaded in a single document, the
DKA Protocol Toolkit, or as individual documents:
The
DKA Medical Protocol can also be downloaded in fillable PDF format (2024/12/10 version). This version auto-calculates the fluid rates and has some pop-up screens to guide in the clinical evaluation of children presenting with DKA.
We have made available a slide set for use with presenting the BCCH DKA Protocol 2024 revision to other professionals:
The major modifications from the previous version (dated 2019/10/08) of the protocol include:
- DKA is now defined as blood glucose ≥11.1 mmol/L, moderate–large ketonuria (≥2+) or plasma β-hydroxybutyrate ≥3.0 mmol/L, and venous pH <7.3 or plasma bicarbonate <18 mmol/L (previously 15 mmol/L).
- More-aggressive fluid boluses are suggested at the start of therapy: most patients with DKA should receive a 20-mL/kg bolus of normal saline at the beginning; those with poor cardiovascular function will require additional fluid boluses until stable.
- An insulin infusion rate of 0.05 U/kg/h is suggested when pH >7.15.
- Notation is added not to begin KCl unless patient is urinating and has plasma K+ ≤5.5 mmol/L.
- Notation is added not to begin insulin unless plasma K+ ≥3.5 mmol/L.
We hope that you will find these materials to be helpful in managing pediatric cases of diabetic ketoacidosis. Please do not hesitate to contact the Endocrinology & Diabetes Unit at BCCH for any help in implementing this protocol at your health-care centre in British Columbia. We also welcome any suggestions to make this material more useful to your practice.
This should be suspected when there are significant elevations in the blood glucose (>33.3 mmol/L) and effective serum osmolality (>320 mOsm/L) without significant ketosis or acidosis (arterial pH >7.30, venous pH >7.25, bicarbonate >15 mmol/L). Obtundation, combativeness, or seizures occur in approximately 50% of patients. HHS is more likely in type 2 diabetes, or in type 1 diabetes when the patient has been consuming large quantities of glucose-containing drinks. Some patients can present with a mixed picture of both HHS and DKA. HHS is associated with more serious volume depletion, and the management of HHS differs from that of DKA.
The
International Society for Pediatric and Adolescent Diabetes (ISPAD) have published their
2022 guidelines for the management of HHS.
As well, the
Canadian Pediatric Endocrine Group have published their
Hyperglycemic Hyperosmolar State (HHS) Guidelines (2023).
The following information, i.e. guideline/educational material/policy or procedure, has been developed for use only within BC Children’s Hospital. There are support systems at BC Children’s Hospital that may not exist in other clinical settings and therefore any adoption of these materials cannot be the responsibility of BC Children’s. Agencies other than BC Children’s Hospital should use this information as a guideline for reference purposes only. All materials are the property of BC Children’s Hospital and may only be reprinted in whole or in part with our expressed permission.
