Managing diabetic ketoacidosis in special conditions: Difficulties and dilemmas

Table 2 Comparison of major pediatric diabetic ketoacidosis management guidelines from different countries

Management aspects	ISPAD Guidelines	BSPED (United Kingdom)	CPS (Canada)
Fluid therapy (initial bolus)	Recommends 0.45% or 0.9% NaCl or balanced salt solutions. Infuse fluids (10 mL/kg) over 30-60 minutes for those not in shock; may repeat1	Infuse 10 mL/kg bolus over 60 minutes to all patients managed with i.v. fluids (not in shock)	Administer 10-20 mL/kg (to a maximum 1000 mL) of isotonic fluid with 0.9% NaCl or a balanced crystalloid for all patients over 20-30 minutes
Insulin administration	Continuous insulin infusion at 0.05-0.1 unit/kg/hour starting 1 hour after fluids initiated (0.05 units/kg/hour for mild DKA)	Rate of 0.1 units/kg/hour	Rate of 0.05-0.1 units/kg/hour similar to ISPAD but recommends decreasing to 0.025 units/kg/hour if BG falls rapidly or as a bridge to s.c. insulin
Electrolyte management	Start replacing potassium after initial volume expansion and concurrent with starting insulin therapy2; The starting potassium concentration in the infusate should be 40 mmol/L	Use 0.9% NaCl with 20 mmol KCl in 500 mL (or 40 mmol in a L)	Supplemental potassium of at least 40 mmol/L should be added to i.v. fluids when potassium is < 5 mmol/L and after recent urine output is documented
Glucose introduction	Suggests adding 5% dextrose before glucose levels fall to 17 mmol/L if dropping rapidly or at 14-17 mmol/L	Use glucose-containing fluids once plasma glucose drops to < 14 mmol/L	Dextrose (usually 5%) should be added when glucose level is between 15 and 17 mmol/L.

¹Fluid resuscitation during shock - 20 mL/kg 0.9% NaCl intravenous bolus, which is not subtracted from the total fluid deficit.

²If potassium is given with the initial rapid volume expansion, a concentration of 20 mmol/L should be used.

BSPED: British Society for Paediatric Endocrinology and Diabetes; CPS: Canadian Paediatric Society; DKA: Diabetic ketoacidosis; ISPAD: International Society for Pediatric and Adolescent Diabetes; i.v.: Intravenous; s.c.: Subcutaneous.