Diabetic Ketoacidosis is a complication of new or existing Type 1 Diabetes. Pediatric DKA may be complicated by cerebral edema and due to this risk, is treated differently than adult DKA. Health care providers must follow a published pediatric-specific protocol when treating pediatric DKA. We have chosen 3 examples of such protocols: a general treatment algorithm from the Canadian Diabetes Association, a detailed treatment algorithm from BC Children's Hospital (English) and a detailed treatment algorithm from Centre hospitalier universitaire Sainte-Justine (French). Each pediatric hospital in Canada will have a protocol that they follow, thus early communication with the diabetes specialist at your pediatric referral site is a key element of the management of these patients.



Bottom Line Recommendations

Bottom Line Recommendations: Diabetic Ketoacidosis


Reid, S & TREKK Network

Bottom line recommendations for the treatment and management of diabetic ketoacidosis (DKA).

Recommendations de Base: Acidocetose Diabtique (ACD)


Reid, S, & TREKK Network

Bottom line recommendations for the treatment and management of diabetic ketoacidosis (DKA).

Bottom Line: Diabetic Ketoacidosis Protocol: For Children up to Age 19 Years


BC Children's Hospital

This protocol is designed as an algorithm for treating the majority of cases of diabetic ketoacidosis in infants, children and adolescents.

Bottom Line: Immediate Assessment and Magement of Diabetic Ketoacidosis (DKA) in Children


Wherrett, D, Huot, C, Mitchell, B, & Pacaud, D

Figure from Canadian Diabetes Association Clincial Practice Guidelines on Type 1 Diabetes in Children and Adolescents.

Clinical guidelines

Clinical Practice Guideline: ISPAD Clinical Practice Consensus Guidelines 2014 Compendium: Diabetic ketoacidosis and hyperglycemic hyperosmolar state


Wolfsdorf, J, Allgrove, J, Craig, M, Edge, J, Glaser, N, Jain, V, Lee, W, Mun...

The following recommendations are based on currently available evidence and are intended only as a general guide to DKA management. Because there is considerable individual variability in presentation of DKA (ranging from mild with only minimal dehydration to severe with profound dehydration),some patients may require specific treatment that, in the judgment of the treating physician, may be within or, occasionally, outside the range of options presented here.

Clinical Practice Guideline: Type 1 Diabetes in Children and Adolescents


Wherrett, D, Huot, C, Mitchell, B, & Pacaud, D

This section addresses those areas of type 1 diabetes management that are specific to children. Key Messages: 1) Suspicion of diabetes in a child should lead to immediate confirmation of the diagnosis and initiation of treatment to reduce the likelihood of diabetic ketoacidosis (DKA). 2) Management of pediatric DKA differs from DKA in adults because of the increased risk for cerebral edema. Pediatric protocols should be used. 3) Children should be referred for diabetes education, ongoing care and psychosocial support to a diabetes team with pediatric expertise.

Clinical Practice Guideline: Diabetic ketoacidosis in children and adolescents: An update and revised treatment protocol


Metzger, D

The protocol assists the medical practitioner in calculating fluid and electrolyte replacement needs for individual patients and outlines a plan for initial assessment and ongoing monitoring.

Systematic reviews

Systematic Review: Bicarbonate in diabetic ketoacidosis


Chua, HR, Schneider, A, & Bellomo, R

Objective: This study was designed to examine the efficacy and risk of bicarbonate administration in the emergent treatment of severe acidemia in diabetic ketoacidosis (DKA).

Systematic Review: Factors associated with the presence of diabetic ketoacidosis at diagnosis of diabetes in children and young adults


Usher-Smith, JA, Thompson, MJ, Sharp, SJ, & Walter, FM

Objective: To identify the factors associated with diabetic ketoacidosis at diagnosis of type 1 diabetes in children and young adults.

Critically Appraised Topic: Evidence-based emergency medicine/critically appraised topic. Is fluid therapy associated with cerebral edema in children with diabetic ketoacidosis?


Hom, J, & Sinert, R

Diabetic ketoacidosis is the most common cause of morbidity and mortality in children with type I diabetes mellitus, and cerebral edema is the leading cause of pediatric diabetic ketoacidosis death. Excessive intravenous fluid administration has been implicated as a cause of cerebral edema. We perform an evidence-based emergency medicine review assessing the association of intravenous fluid hydration and cerebral edema.

Systematic Review: Cerebral edema in diabetic ketoacidosis


Levin, DL

Objective: To review the causes of cerebral edema in diabetic ketoacidosis (CEDKA), including pathophysiology, risk factors, and proposed mechanisms, to review the diagnosis, treatment, and prognosis of CEDKA and the treatment of diabetic ketoacidosis as it pertains to prevention of cerebral edema.

Key studies

Key Study: How can cerebral edema during treatment of diabetic ketoacidosis be avoided?


Watts, W, & Edge, JA

This article discusses how DKA might be prevented from occurring in the first instance, known risk factors for cerebral edema, fluid and insulin management, the importance of careful monitoring during DKA treatment, and the importance of recognizing and acting on the earliest symptoms to prevent long-term harm.

Key Study: Subclinical cerebral edema in children with diabetic ketoacidosis randomized to 2 different rehydration protocols


Glaser, NS, Wootton-Gorges, SL, Buonocore, MH, Tancredi, DJ, Marcin, JP, Calt...

Previous studies show that vasogenic cerebral edema (CE) occurs during diabetic ketoacidosis (DKA) treatment in children, but the role of intravenous fluids in contributing to CE is unclear. We used magnetic resonance diffusion weighted imaging to quantify subclinical CE in children with DKA randomized to 2 intravenous fluid regimens.

Key Study: Dehydration in children with diabetic ketoacidosis: A prospective study


Sottosanti, M, Morrison, GC, Singh, RN, Sharma, AP, Fraser, DD, Alawi, K, Sea...

Objective: To investigate the association between the degree of patient dehydration on presentation with diabetic ketoacidosis (DKA) and clinical and laboratory parameters obtained on admission.

Key Study: Measured degree of dehydration in children and adolescents with type 1 diabetic ketoacidosis


Ugale, J, Mata, A, Meert, KL, & Sarnaik, AP

Objectives: 1) measure the degree of dehydration in children with type 1 diabetes mellitus and diabetic ketoacidosis based on change in body weight; and 2) investigate the relationships between measured degree of dehydration and clinically assessed degree of dehydration, severity of diabetic ketoacidosis, and routine serum laboratory values.

Key Study: Initial fluid resuscitation for patients with diabetic ketoacidosis: how dry are they?


Fagan, MJ, Avner, J, & Khine, H

A prospective consecutive case series of patients aged 5 to 20 years who presented to a pediatric emergency department with diabetic ketoacidosis (DKA) was studied to determine the actual percent loss of body weight during an episode of DKA to determine the degree of dehydration and thereby provide a guide for hydration therapy during such an episode.

Key Study: Conscious level in children with diabetic ketoacidosis is related to severity of acidosis and not to blood glucose concentration


Edge, JA, Roy, Y, Bergomi, A, Murphy, NP, Ford-Adams, ME, Ong, KK, & Dung...

Objective: To ascertain whether initial depression of conscious level in children with diabetic ketoacidosis (DKA) is related to hyperosmolality, acidosis or other factors.

Key Study: The UK case-control study of cerebral oedema complicating diabetic ketoacidosis in children


Edge, JA, Jakes, RW, Roy, Y, Hawkins, M, Winter, D, Ford-Adams, ME, Murphy, N...

Cerebral oedema complicating diabetic ketoacidosis (DKA) remains the major cause of morbidity and mortality in children with type 1 diabetes, but its aetiology remains unknown. Our objective was to determine the impact of baseline biochemical factors and of treatment-related variables on risk of the development of cerebral oedema in children with DKA.

Key Study: Population-based study of incidence and risk factors for cerebral edema in pediatric diabetic ketoacidosis


Lawrence, SE, Cummings, EA, Gaboury, I, & Daneman, D

Objectives: To determine incidence, outcomes, and risk factors for pediatric cerebral edema with diabetic ketoacidosis (CEDKA) in Canada.

Key Study: Risk factors for cerebral edema in children with diabetic ketoacidosis. The Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics


Glaser, N, Barnett, P, McCaslin, I, Nelson, D, Trainor, J, Louie, J, Kaufman,...

Cerebral edema is an uncommon but devastating complication of diabetic ketoacidosis in children. Risk factors for this complication are defined in this multicenter study.