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Diabetic ketoacidosis is a complication of new or existing pediatric diabetes and may be complicated by cerebral injury. Due to this risk, is treated differently than adult DKA. Health care providers must follow a published pediatric-specific protocol when treating pediatric DKA. Early communication with the diabetes specialist at your pediatric referral site is a key element of the management of these patients.

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Bottom Line Recommendations English (5) French (4) All (9)

Diabetic Ketoacidosis References and Development Team

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TREKK Diabetic Ketoacidosis PedsPac

This document outlines the references used and team involved in the development of the diabetic ketoacidosis PedsPac. Published online: January 2019.

Bottom Line Recommendations: Diabetic Ketoacidosis

Download

Reid S, and TREKK Network

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

Diabetic Keotacidosis Algorithm

Download

TREKK Diabetic Ketoacidosis PedsPac

An algorithm for recognizing and managing pediatric diabetic ketoacidosis

Diabetic Ketoacidosis Pocket Card

Download

TREKK Diabetic Ketoacidosis PedsPac

A pocket guide to red flags for pediatric diabetic ketoacidosis

Diabetic Ketoacidosis Order Set

Download

TREKK Diabetic Ketoacidosis PedsPac

This order set is for management of pediatric diabetic ketoacidosis in the ED. This document is adaptable to your hospitals form policy. Published online: July 2019, Version 1.1.

Recommandations de Base: Acidose Diabetique

Download

Reid S, and TREKK Network

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

Feuille d'Ordonnance Medicale pour d'Acidose Diabetique

Download

TREKK Diabetic Ketoacidosis PedsPac

This order set is for management of pediatric diabetic ketoacidosis in the ED. This document is adaptable to your hospitals form policy. Published online: July 2019, Version 1.1 - French.

Carte de Poche d'Acidose Diabetique

Download

TREKK Diabetic Ketoacidosis PedsPac

A pocket guide to red flags for pediatric diabetic ketoacidosis - French

Algorithme Pediatrique pour d'Acidose Diabetique

Download

TREKK Diabetic Ketoacidosis PedsPac

An algorithm for recognizing and managing pediatric diabetic ketoacidosis - French

Diabetic Ketoacidosis References and Development Team

Download

TREKK Diabetic Ketoacidosis PedsPac

This document outlines the references used and team involved in the development of the diabetic ketoacidosis PedsPac. Published online: January 2019.

Bottom Line Recommendations: Diabetic Ketoacidosis

Download

Reid S, and TREKK Network

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

Recommandations de Base: Acidose Diabetique

Download

Reid S, and TREKK Network

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

Diabetic Keotacidosis Algorithm

Download

TREKK Diabetic Ketoacidosis PedsPac

An algorithm for recognizing and managing pediatric diabetic ketoacidosis

Diabetic Ketoacidosis Pocket Card

Download

TREKK Diabetic Ketoacidosis PedsPac

A pocket guide to red flags for pediatric diabetic ketoacidosis

Diabetic Ketoacidosis Order Set

Download

TREKK Diabetic Ketoacidosis PedsPac

This order set is for management of pediatric diabetic ketoacidosis in the ED. This document is adaptable to your hospitals form policy. Published online: July 2019, Version 1.1.

Feuille d'Ordonnance Medicale pour d'Acidose Diabetique

Download

TREKK Diabetic Ketoacidosis PedsPac

This order set is for management of pediatric diabetic ketoacidosis in the ED. This document is adaptable to your hospitals form policy. Published online: July 2019, Version 1.1 - French.

Carte de Poche d'Acidose Diabetique

Download

TREKK Diabetic Ketoacidosis PedsPac

A pocket guide to red flags for pediatric diabetic ketoacidosis - French

Algorithme Pediatrique pour d'Acidose Diabetique

Download

TREKK Diabetic Ketoacidosis PedsPac

An algorithm for recognizing and managing pediatric diabetic ketoacidosis - French

Clinical guidelines English (2) French All (2)

ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state

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Wolfsdorf J, Glaser N, Agus M, Fritsch M, Hanas R, Rewers A, Sperling M, and...

Recommendations concerning fluid management have been modified to reflect recent findings from a randomized controlled clinical trial showing no difference in cerebral injury in patients rehydrated at different rates with either 0.45% or 0.9% saline.

Diabetes Canada 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada: Type 1 Diabetes in Children and Adolescents

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Wherrett D, Ho J, Huot C, et al

Diabetes mellitus is the most common endocrine disease and one of the most common chronic conditions in children. Type 2 diabetes and other types of diabetes, including genetic defects of beta cell function, such as monogenic and neonatal diabetes, are being increasingly recognized in children and should be considered when clinical presentation is atypical for type 1 diabetes. This section addresses those areas of type 1 diabetes management that are specific to children.

ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state

Visit

Wolfsdorf J, Glaser N, Agus M, Fritsch M, Hanas R, Rewers A, Sperling M, and...

Recommendations concerning fluid management have been modified to reflect recent findings from a randomized controlled clinical trial showing no difference in cerebral injury in patients rehydrated at different rates with either 0.45% or 0.9% saline.

Diabetes Canada 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada: Type 1 Diabetes in Children and Adolescents

Visit

Wherrett D, Ho J, Huot C, et al

Diabetes mellitus is the most common endocrine disease and one of the most common chronic conditions in children. Type 2 diabetes and other types of diabetes, including genetic defects of beta cell function, such as monogenic and neonatal diabetes, are being increasingly recognized in children and should be considered when clinical presentation is atypical for type 1 diabetes. This section addresses those areas of type 1 diabetes management that are specific to children.

Systematic reviews English (3) French All (3)

Systematic Review: Bicarbonate in diabetic ketoacidosis

Visit

Chua HR, Schneider A, and 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

Visit

Usher-Smith JA, Thompson MJ, Sharp SJ, and 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?

Visit

Hom J, and 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: Bicarbonate in diabetic ketoacidosis

Visit

Chua HR, Schneider A, and 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

Visit

Usher-Smith JA, Thompson MJ, Sharp SJ, and 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?

Visit

Hom J, and 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.

Key studies English (16) French All (16)

Key Study: Effect of potassium infusion on serum levels in children during treatment of diabetic ketoacidosis

Visit

Musaitif R and Basnet S

Objectives: to determine the effect of 40 mEq/L and 60 mEq/L infusions on potassium levels in children during treatment of DKA.

Key Study: Improving Emergency Department Management of Diabetic Ketoacidosis in Children

Visit

Baumer-Mouradian SH, Gray MP, Wolfgram PM, Kopetsky M, Chang F, Brousseau DC,...

Objectives: To use point-of-care (POC) testing to reduce DKA determination time from 86 to 30 minutes and to reduce IV placements in patients without DKA from 85% to 20% over 18 months.

Key Study: Improving Pediatric Diabetic Ketoacidosis Management in Community Emergency Departments Using a Simulation-Based Collaborative Improvement Program

Visit

Abulebda K, Whitfill T, Montgomery EE, Kirby ML, Ahmed RA, Cooper DD, Nitu ME...

Objectives: The majority of pediatric patients with diabetic ketoacidosis (DKA) present to community emergency departments (CEDs) that are less prepared to care for acutely ill children owing to low pediatric volume and limited pediatric resources and guidelines. This has impacted the quality of care provided to pediatric patients in CEDs. We hypothesized that a simulation-based collaborative program would improve the quality of the care provided to simulated pediatric DKA patients presenting to CEDs.

Key Study: Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis

Visit

Kuppermann N, Ghetti S, Schunk JE, et al

Background: Diabetic ketoacidosis in children may cause brain injuries ranging from mild to severe. Whether intravenous fluids contribute to these injuries has been debated for decades. Methods: This 13-center, randomized, controlled trial examined the effects of the rate of administration and the sodium chloride content of intravenous fluids on neurologic outcomes in children with diabetic ketoacidosis.

Key Study: Adherence to a pediatric diabetic ketoacidosis protocol in children presenting to a tertiary care hospital

Visit

Ronsley R, Islam N, Ronsley C, Metzger DL, and Panagiotopoulos C

Objective: To review adherence to a provincial diabetic ketoacidosis (DKA) protocol and to assess factors associated with intravenous fluid administration and the length time on an insulin infusion.

Key Study: Resuscitation With Ringer's Lactate Compared With Normal Saline for Pediatric Diabetic Ketoacidosis

Visit

Bergmann KR, Abuzzahab MJ, Nowak J, Arms J, Cutler G, Christensen E, Finch M,...

Objective: The aims of this study were to describe the use of Ringer's lactate (LR) or normal saline (NS) for resuscitation among children with diabetic ketoacidosis (DKA) and compare the effect of fluid type on cost, length of stay, and rate of cerebral edema (CE).

Key Study: Controlled trial of Hartmann's solution versus 0.9% saline for diabetic ketoacidosis

Visit

Yung M, Letton G, and Keeley S

Objective: We aimed to determine whether using a balanced salt solution, Hartmann's solution (HS), in diabetic ketoacidosis (DKA) shortens the time to normalise acid-base status through the avoidance of hyperchloremic metabolic acidosis compared with 0.9% normal saline (NS).

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

Visit

Watts W, and 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

Visit

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

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

Visit

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

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

Visit

Ugale J, Mata A, Meert KL, and 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?

Visit

Fagan MJ, Avner J, and 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

Visit

Edge JA, Roy Y, Bergomi A, Murphy NP, Ford-Adams ME, Ong KK, and Dunger DB

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

Visit

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

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

Visit

Lawrence SE, Cummings EA, Gaboury I, and 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

Visit

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

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

Key Study: Effect of potassium infusion on serum levels in children during treatment of diabetic ketoacidosis

Visit

Musaitif R and Basnet S

Objectives: to determine the effect of 40 mEq/L and 60 mEq/L infusions on potassium levels in children during treatment of DKA.

Key Study: Improving Emergency Department Management of Diabetic Ketoacidosis in Children

Visit

Baumer-Mouradian SH, Gray MP, Wolfgram PM, Kopetsky M, Chang F, Brousseau DC,...

Objectives: To use point-of-care (POC) testing to reduce DKA determination time from 86 to 30 minutes and to reduce IV placements in patients without DKA from 85% to 20% over 18 months.

Key Study: Improving Pediatric Diabetic Ketoacidosis Management in Community Emergency Departments Using a Simulation-Based Collaborative Improvement Program

Visit

Abulebda K, Whitfill T, Montgomery EE, Kirby ML, Ahmed RA, Cooper DD, Nitu ME...

Objectives: The majority of pediatric patients with diabetic ketoacidosis (DKA) present to community emergency departments (CEDs) that are less prepared to care for acutely ill children owing to low pediatric volume and limited pediatric resources and guidelines. This has impacted the quality of care provided to pediatric patients in CEDs. We hypothesized that a simulation-based collaborative program would improve the quality of the care provided to simulated pediatric DKA patients presenting to CEDs.

Key Study: Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis

Visit

Kuppermann N, Ghetti S, Schunk JE, et al

Background: Diabetic ketoacidosis in children may cause brain injuries ranging from mild to severe. Whether intravenous fluids contribute to these injuries has been debated for decades. Methods: This 13-center, randomized, controlled trial examined the effects of the rate of administration and the sodium chloride content of intravenous fluids on neurologic outcomes in children with diabetic ketoacidosis.

Key Study: Adherence to a pediatric diabetic ketoacidosis protocol in children presenting to a tertiary care hospital

Visit

Ronsley R, Islam N, Ronsley C, Metzger DL, and Panagiotopoulos C

Objective: To review adherence to a provincial diabetic ketoacidosis (DKA) protocol and to assess factors associated with intravenous fluid administration and the length time on an insulin infusion.

Key Study: Resuscitation With Ringer's Lactate Compared With Normal Saline for Pediatric Diabetic Ketoacidosis

Visit

Bergmann KR, Abuzzahab MJ, Nowak J, Arms J, Cutler G, Christensen E, Finch M,...

Objective: The aims of this study were to describe the use of Ringer's lactate (LR) or normal saline (NS) for resuscitation among children with diabetic ketoacidosis (DKA) and compare the effect of fluid type on cost, length of stay, and rate of cerebral edema (CE).

Key Study: Controlled trial of Hartmann's solution versus 0.9% saline for diabetic ketoacidosis

Visit

Yung M, Letton G, and Keeley S

Objective: We aimed to determine whether using a balanced salt solution, Hartmann's solution (HS), in diabetic ketoacidosis (DKA) shortens the time to normalise acid-base status through the avoidance of hyperchloremic metabolic acidosis compared with 0.9% normal saline (NS).

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

Visit

Watts W, and 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

Visit

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

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

Visit

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

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

Visit

Ugale J, Mata A, Meert KL, and 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?

Visit

Fagan MJ, Avner J, and 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

Visit

Edge JA, Roy Y, Bergomi A, Murphy NP, Ford-Adams ME, Ong KK, and Dunger DB

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

Visit

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

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

Visit

Lawrence SE, Cummings EA, Gaboury I, and 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

Visit

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

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