Complete DKA management in 12 yeas old girl

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ISPAD 2022 diabetic ketoacidosis children management guideline fluid insulin potassium cerebral injury

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PMID: 38572835

DKA management in a 12-year-old girl

This is a pediatric emergency. Manage in an ED/PICU or unit experienced in pediatric DKA, using the hospital’s pediatric DKA fluid calculator and protocol. Seek senior pediatric endocrine and intensive-care input early, particularly with severe DKA, altered consciousness, shock, suspected cerebral injury, or age <5 years.

1. Confirm DKA and assess severity

Diagnostic criteria

Glucose >11 mmol/L (>200 mg/dL)
Venous pH <7.30 or bicarbonate <18 mmol/L
Blood beta-hydroxybutyrate ≥3 mmol/L, or moderate/large urine ketones.

Severity

Severity	Venous pH	Bicarbonate
Mild	<7.30	<18 mmol/L
Moderate	<7.20	<10 mmol/L
Severe	<7.10	<5 mmol/L

Perform immediate ABCDE assessment:

Airway protection if reduced consciousness or recurrent vomiting.
Breathing: assess Kussmaul respiration, oxygen only if hypoxemic.
Circulation: pulse, BP, capillary refill, peripheral perfusion, hydration, weight.
Disability: document GCS/AVPU, pupils, headache, behavior. Repeat neurological observations frequently.
Exposure: fever, infection source, insulin-pump failure, missed insulin, new-onset diabetes, abdominal pain, trauma, drugs.

Do not assume abdominal pain is surgical until DKA treatment has begun, but reassess if pain persists after acidosis improves.

2. Investigations before treatment if this does not delay resuscitation

Bedside glucose and blood ketones.
Venous blood gas: pH, bicarbonate, pCO₂.
Urea, creatinine, electrolytes including sodium, potassium, chloride, phosphate, magnesium, calcium.
Full blood count, urinalysis and culture if indicated.
ECG if potassium abnormal, severe DKA, or cardiac concerns.
Blood culture, chest radiograph, viral testing only if clinical features suggest infection.
HbA1c and diabetes autoantibodies/C-peptide if new diabetes, according to local policy.
Pregnancy test where relevant and appropriate.

Calculate anion gap:

[ AG = Na - (Cl + HCO_3) ]

Trend corrected sodium and effective osmolality using the local protocol. A failure of corrected sodium to rise as glucose falls can be a warning sign for cerebral injury.

3. Fluids: isotonic, calculated, and carefully monitored

If shocked

True shock is uncommon in DKA. If there is hypotension or poor perfusion:

Give 0.9% sodium chloride 10 mL/kg IV over 15-30 minutes.
Reassess after each bolus.
A further bolus may be needed, generally up to 20 mL/kg total, with PICU/senior review.

Do not withhold resuscitation fluids from a genuinely shocked child because of concern about cerebral edema.

If not shocked

Start isotonic fluid, usually 0.9% sodium chloride or a balanced isotonic crystalloid if supported by local policy.
Estimate dehydration clinically:
- Moderate DKA: usually assume about 5% deficit
- Severe DKA: usually assume about 10% deficit
Replace maintenance plus calculated deficit evenly over 48 hours. Include any resuscitation boluses in the total fluid calculation when required by the local protocol.
Do not use hypotonic fluids initially.
Avoid excessive fluid administration and avoid arbitrary high rates.

Urine output target: about 1-2 mL/kg/hour. If anuria/oliguria persists, reassess perfusion, renal function, and potassium administration.

4. Potassium and electrolyte replacement

Children with DKA have a large total-body potassium deficit, even if the initial serum potassium is normal or high.

Potassium approach

Obtain potassium before insulin if possible.
Add potassium to IV fluids once the child has passed urine and renal function is satisfactory, commonly 40 mmol/L in pediatric DKA protocols.
Use a mixture of potassium salts where available, for example potassium chloride plus potassium phosphate/acetate, to reduce chloride load and replace phosphate.

Serum K+	Action
<3.0 mmol/L	Do not start insulin yet. Begin monitored potassium replacement and correct K+ first. Continuous ECG monitoring.
3.0-5.5 mmol/L	Add potassium to IV fluids and start insulin after fluids have begun.
>5.5 mmol/L	Do not add potassium initially. Check frequently and add once K+ falls and urine output is established.

Check potassium at least every 2 hours during initial treatment.
Continuous ECG monitoring for severe DKA, hypokalemia/hyperkalemia, or significant electrolyte abnormality.
Replace phosphate only if significantly low or if there is cardiac dysfunction, respiratory weakness, hemolysis, or other clinical indication. Monitor calcium if phosphate is given.

5. Insulin infusion

Never give an IV insulin bolus in pediatric DKA.

Begin insulin 1-2 hours after starting IV fluids, once potassium is safe.
Use regular/soluble insulin infusion:
- 0.05 units/kg/hour is appropriate for most children.
- 0.1 units/kg/hour may be considered in severe DKA or in some adolescents, under local protocol.
Stop any insulin pump once IV insulin begins.
Continue basal long-acting insulin in a child already using it if consistent with the local endocrine protocol.

Treatment goals

Glucose should decline gradually, typically about 3-5 mmol/L/hour (50-90 mg/dL/hour).
The endpoint is resolution of ketoacidosis, not simply normalization of glucose.

6. Add dextrose while continuing insulin

When glucose falls to approximately 14-17 mmol/L (250-300 mg/dL):

Add 5% dextrose to the isotonic fluid.
Increase to 10% dextrose if glucose continues to fall too quickly or is <8-10 mmol/L while ketones/acidosis persist.

Do not stop insulin merely because glucose normalizes. Increase dextrose instead, while continuing insulin until ketoacidosis resolves.

7. Monitoring schedule

Hourly

Vital signs, hydration/perfusion, respiratory effort.
GCS/neurological observations and headache assessment.
Capillary blood glucose.
Strict fluid input/output, including urine output.
Insulin infusion rate and IV fluid rate.

Every 1-2 hours initially

Venous blood gas: pH, bicarbonate.
Electrolytes, especially potassium and sodium.
Blood beta-hydroxybutyrate, if available.

Every 2-4 hours

Urea/creatinine, phosphate, magnesium, calcium as indicated.
Recalculate anion gap and review corrected sodium trend.

Expected response

Glucose falls gradually.
Ketones fall by about ≥0.5 mmol/L/hour when measurable.
Bicarbonate rises and anion gap closes.
Clinical dehydration and Kussmaul breathing improve.

8. Cerebral injury/cerebral edema: recognize and treat immediately

Cerebral injury is the major life-threatening pediatric DKA complication. It may occur before or during treatment.

Warning signs

New or worsening headache.
Irritability, confusion, altered behavior, drowsiness.
Falling GCS, incontinence, cranial nerve palsy.
Recurrent vomiting.
Bradycardia, hypertension, abnormal respiratory pattern.
Seizure.

If suspected

Call PICU/emergency senior help immediately.
Elevate head of bed to about 30 degrees and keep head midline.
Reduce IV fluid rate to the minimum needed to maintain circulation.
Give one of the following without waiting for CT:
- Mannitol 0.5-1 g/kg IV over 10-15 minutes, or
- 3% hypertonic saline 2.5-5 mL/kg IV over 10-15 minutes.
Prepare for controlled airway support if deteriorating. Avoid unnecessary hyperventilation. Brief hyperventilation may be used only if there are signs of imminent herniation while definitive care is arranged.
Perform neuroimaging only after treatment has started and the child is stabilized. Imaging must not delay osmotherapy.

9. Treatments to avoid

No insulin bolus.
No routine sodium bicarbonate. Consider only with expert PICU/endocrine guidance for life-threatening hyperkalemia or severe acidosis with impaired myocardial contractility.
No routine phosphate replacement.
No hypotonic fluid early in management.
No oral fluids initially in a child with significant vomiting, altered consciousness, or severe DKA.
Do not stop insulin before ketone clearance/acidosis resolution.

10. Resolution and transition to subcutaneous insulin

DKA is generally resolved when the child is clinically well, able to drink/eat, and has:

pH >7.30
Bicarbonate ≥15-18 mmol/L
Closing/normal anion gap
Blood ketones <1 mmol/L or clearly resolving.

Transition

Give the first subcutaneous rapid-acting insulin dose 15-30 minutes before stopping IV insulin.
If using long-acting basal insulin, give it early enough to ensure overlap, often 2-4 hours before discontinuing IV insulin depending on the product and local policy.
Restart usual meal plan and carbohydrate counting when tolerated.
For newly diagnosed type 1 diabetes, institute a basal-bolus regimen with pediatric diabetes-team teaching before discharge.

11. Identify and address the precipitant

Common triggers include:

New-onset type 1 diabetes.
Missed insulin doses, access issues, or psychosocial difficulties.
Pump/cannula failure.
Intercurrent infection.
Eating disorder or intentional insulin omission in adolescents.

Before discharge, provide sick-day rules, ketone testing instructions, insulin-pump troubleshooting if relevant, and clear return precautions.

The ISPAD pediatric DKA guideline and BSPED pediatric protocol support delayed low-dose IV insulin after fluids, careful potassium replacement, avoidance of insulin boluses/bicarbonate, and prompt empiric treatment of suspected cerebral injury.

Evidence update: A 2024 systematic review found insufficient high-quality evidence to identify one superior pediatric fluid type, tonicity, volume, or administration schedule, so local pediatric DKA protocols remain important (PMID 38572835).

Make a fluid and insulin calculation example by weight

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BSPED DKA guideline fluid calculation 5% 10% deficit 48 hours maintenance children insulin 0.05 units/kg/hour

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"diabetic ketoacidosis" AND child AND fluid

Example: 12-year-old girl weighing 40 kg with moderate DKA

Assumptions

pH 7.15, so moderate DKA
Estimated dehydration: 5%
Not in shock
Initial 0.9% saline bolus 10 mL/kg over 30 minutes
Use the BSPED-style calculation: replace remaining deficit over 48 hours plus maintenance. Use your hospital’s pediatric DKA calculator/protocol.

1. Initial fluid bolus

[ 10\ \text{mL/kg} \times 40\ \text{kg} = 400\ \text{mL} ]

Give 400 mL 0.9% sodium chloride IV over 30 minutes.

2. Calculate fluid deficit

For 5% dehydration:

[ 5% \times 40\ \text{kg} = 2\ \text{kg fluid loss} = 2000\ \text{mL} ]

Subtract the initial bolus from the deficit:

[ 2000 - 400 = 1600\ \text{mL} ]

Replace this over 48 hours:

[ 1600 \div 48 = 33.3\ \text{mL/hour} ]

3. Maintenance fluid rate

Using the pediatric DKA maintenance rule used in this protocol:

10-40 kg: 1 mL/kg/hour

[ 40\ \text{kg} \times 1\ \text{mL/kg/hour} = 40\ \text{mL/hour} ]

4. Total ongoing IV fluid rate

[ 33.3\ \text{mL/hour deficit replacement} + 40\ \text{mL/hour maintenance} = 73.3\ \text{mL/hour} ]

Prescription after the bolus

Start 0.9% sodium chloride at 73 mL/hour
Add potassium as indicated by serum potassium, urine output, ECG, and local policy.
When blood glucose reaches about 14-17 mmol/L (250-300 mg/dL), add 5% dextrose while continuing the insulin infusion.

Insulin calculation

Start IV regular/soluble insulin 1-2 hours after fluids begin, after confirming potassium is safe. No IV insulin bolus.

Standard starting dose: 0.05 units/kg/hour

[ 0.05\ \text{units/kg/hour} \times 40\ \text{kg} = 2\ \text{units/hour} ]

Prescription

Regular insulin IV infusion: 2 units/hour

If the child has severe DKA or the local protocol directs 0.1 units/kg/hour:

[ 0.1 \times 40 = 4\ \text{units/hour} ]

So the alternative rate is 4 units/hour, but 0.05 units/kg/hour is often sufficient in children.

If making an insulin infusion syringe

A common preparation is:

50 units regular insulin in 50 mL 0.9% saline
Final concentration: 1 unit/mL

For this 40 kg child at 2 units/hour:

[ 2\ \text{units/hour} = 2\ \text{mL/hour} ]

Run the insulin syringe pump at 2 mL/hour.

Potassium example

If potassium is 3.5-5.5 mmol/L, urine output is established, and renal function is acceptable:

Use the calculated fluid rate: 73 mL/hour
Give isotonic fluid with potassium, often 40 mmol/L total potassium per local protocol.

If K+ is <3.0 mmol/L, hold insulin and replace potassium first. If K+ is high, do not add potassium initially, but recheck frequently and add it once safe.

Quick calculation table

Weight	5% deficit	10 mL/kg bolus	Remaining deficit	Deficit rate over 48 h	Maintenance	Total ongoing rate	Insulin 0.05 U/kg/h
20 kg	1000 mL	200 mL	800 mL	17 mL/h	30 mL/h*	47 mL/h	1 U/h
30 kg	1500 mL	300 mL	1200 mL	25 mL/h	30 mL/h	55 mL/h	1.5 U/h
40 kg	2000 mL	400 mL	1600 mL	33 mL/h	40 mL/h	73 mL/h	2 U/h
50 kg	2500 mL	500 mL	2000 mL	42 mL/h	40 mL/h	82 mL/h	2.5 U/h

*For this DKA-specific maintenance rule: <10 kg = 2 mL/kg/h; 10-40 kg = 1 mL/kg/h; >40 kg = 40 mL/h. Protocols differ, particularly regarding bolus subtraction, fluid type, maximum weight, and deficit assessment.

For severe DKA with pH <7.1, calculate a 10% deficit, not 5%, and involve PICU early. The BSPED pediatric DKA protocol uses the formula:

[ \text{Hourly fluid rate} = \frac{\text{deficit - initial 10 mL/kg bolus}}{48} + \text{maintenance/hour} ]

Use this as an educational example only. Actual pediatric DKA fluids must be prescribed from a local approved protocol with serial electrolyte, neurological, and glucose monitoring.

In25 kg girl complete management of DKA about fluid and also about insulin infusion and it's rate

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site:bsped.org.uk DKA 2023 guideline children fluid calculation insulin infusion 0.05 0.1 units kg hour potassium

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25 kg girl with DKA: fluid and insulin calculation

Use a pediatric DKA protocol/PICU supervision. The exact rate depends on DKA severity, shock status, serum potassium, sodium trend, urine output, and local policy.

Below is a worked example using a common BSPED-style 48-hour calculation.

A. If moderate DKA, not shocked

Assume:

Weight = 25 kg
pH ≥7.1, so estimate 5% dehydration
No hypotension/shock
Initial 0.9% sodium chloride bolus = 10 mL/kg

1. Initial fluid bolus

[ 10\text{ mL/kg} \times 25\text{ kg} = 250\text{ mL} ]

Give 0.9% sodium chloride 250 mL IV over 30 minutes.

If clinically shocked, give this urgently and reassess. Further boluses require senior/PICU review.

2. Deficit calculation

For 5% dehydration:

[ 0.05 \times 25\text{ kg} = 1.25\text{ kg} = 1250\text{ mL} ]

Subtract the initial 250 mL bolus:

[ 1250 - 250 = 1000\text{ mL} ]

Replace the remaining deficit evenly over 48 hours:

[ 1000 \div 48 = 20.8\text{ mL/hour} ]

3. Maintenance fluid calculation

Using 100/50/20 mL/kg/day:

Weight portion	Calculation	Volume/day
First 10 kg	10 × 100 mL	1000 mL
Next 10 kg	10 × 50 mL	500 mL
Remaining 5 kg	5 × 20 mL	100 mL
Total maintenance		1600 mL/day

[ 1600 \div 24 = 66.7\text{ mL/hour} ]

4. Ongoing fluid rate

[ 20.8\text{ mL/h deficit replacement} + 66.7\text{ mL/h maintenance} = 87.5\text{ mL/h} ]

Prescription after the initial bolus

0.9% sodium chloride at approximately 88 mL/hour
Replace over 48 hours.
Use a two-bag system or add dextrose once glucose falls to approximately 14-17 mmol/L (250-300 mg/dL), while insulin continues.

Potassium

Potassium is chosen from the initial serum K+, repeat K+, ECG, kidney function, and urine output.

Serum K+	Action
<3.0 mmol/L	Hold insulin. Give potassium with ECG monitoring until K+ is safe.
3.0-5.5 mmol/L	Add potassium to fluids after urine output is established. A common prescription is 40 mmol/L total potassium, per local policy.
>5.5 mmol/L	Do not add K+ initially. Check frequently and add once K+ falls and the child is passing urine.

B. Insulin infusion for 25 kg

Start regular/soluble IV insulin 1-2 hours after starting IV fluids, only after verifying potassium is not dangerously low.

Do not give an IV insulin bolus.

Standard pediatric rate

[ 0.05\text{ units/kg/hour} \times 25\text{ kg} = 1.25\text{ units/hour} ]

Insulin prescription

Regular insulin infusion: 1.25 units/hour

A rate of 0.05 units/kg/hour is generally appropriate for most children.

If severe DKA or local protocol uses 0.1 units/kg/hour

[ 0.1\text{ units/kg/hour} \times 25\text{ kg} = 2.5\text{ units/hour} ]

Regular insulin infusion: 2.5 units/hour

Use 0.1 units/kg/hour only according to senior/local pediatric DKA guidance, often for severe DKA.

Insulin syringe-pump calculation

Common preparation:

[ 50\text{ units regular insulin in 50 mL 0.9% saline} ]

This gives:

[ 1\text{ unit/mL} ]

Insulin dose	Pump rate with 1 unit/mL preparation
0.05 U/kg/h = 1.25 U/h	1.25 mL/h
0.1 U/kg/h = 2.5 U/h	2.5 mL/h

Prime the infusion tubing with insulin solution according to the hospital policy before connecting it, because insulin adsorbs to tubing.

C. If she has severe DKA, pH <7.1

Assume 10% dehydration.

Fluid calculation

[ 10% \times 25\text{ kg} = 2500\text{ mL deficit} ]

Subtract the routine initial 10 mL/kg bolus:

[ 2500 - 250 = 2250\text{ mL} ]

Deficit replacement rate:

[ 2250 \div 48 = 46.9\text{ mL/hour} ]

Maintenance remains:

[ 66.7\text{ mL/hour} ]

Total continuing fluid rate:

[ 46.9 + 66.7 = 113.6\text{ mL/hour} ]

Severe DKA ongoing rate

Approximately 114 mL/hour after the initial 250 mL bolus, subject to PICU/local DKA protocol.

D. Essential monitoring and adjustments

Bedside glucose: hourly
Neurological observations, pulse, BP, respiratory rate, fluid input/output: hourly
Venous gas, Na+, K+, bicarbonate: initially every 1-2 hours, then as protocol directs
Blood ketones: every 1-2 hours if available
Strict urine output monitoring
Target glucose fall: roughly 3-5 mmol/L/hour. If glucose falls too quickly, add/increase dextrose, rather than stopping insulin.

When glucose is <14-17 mmol/L:

Change to fluid containing 5% dextrose.
If glucose remains low but ketosis persists, use 10% dextrose as required.
Continue insulin until ketoacidosis resolves, not merely until glucose becomes normal.

Never routinely give bicarbonate in pediatric DKA. It is reserved for exceptional situations such as life-threatening hyperkalemia or severe acidosis impairing cardiac function, with PICU input.

This approach follows the BSPED pediatric DKA guideline, which supports fluid-deficit replacement over 48 hours and insulin at 0.05-0.1 units/kg/hour, started 1-2 hours after fluid therapy.

Find the latest pediatric DKA guidelines

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latest pediatric diabetic ketoacidosis guideline 2025 2026 ISPAD BSPED CPS ADA

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https://www.bsped.org.uk/clinical-resources/bsped-dka-guidel…

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PMID: 39563039

Latest pediatric DKA guidelines found

Organization	Guideline	Most recent date	Best use
Chinese Pediatric Society / multidisciplinary panel	Guideline for the management of diabetic ketoacidosis in children (2024)	2024	Most recently published pediatric-specific DKA practice guideline found. Published in Chinese. PubMed record, PMID 39563039
ISPAD	Clinical Practice Consensus Guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state	2022	Main international pediatric reference, applicable broadly for children and adolescents. ISPAD 2022 guideline
BSPED, UK	Management of children and young people <18 years with DKA	Guideline: 2021; full document page updated 26 Nov 2024	Practical UK bedside guideline, calculator, integrated-care pathway, and algorithm. BSPED guideline hub
Canadian Paediatric Society	Current recommendations for management of paediatric DKA	Current online position statement	Concise, evidence-based management summary, especially useful for initial fluids and cerebral injury. CPS recommendations
ADA Standards of Care	Children and Adolescents: Standards of Care in Diabetes 2026	2026	Current US diabetes standards, but not a detailed bedside pediatric DKA fluid-calculation protocol. ADA 2026 standards

Practical recommendation

For bedside treatment of a child, use:

Your hospital’s approved pediatric DKA pathway, because fluid calculation, potassium concentration, bag composition, and escalation thresholds vary by service.
ISPAD 2022 as the main international reference.
BSPED 2021, updated resource page 2024 if you need a clear 48-hour fluid calculator, insulin infusion details, and an accessible treatment algorithm.
The 2024 Chinese guideline is newer, but availability and practical use may be limited for non-Chinese readers.

Key points shared by current major guidelines

Give isotonic IV fluids early. A 10-20 mL/kg isotonic bolus in the first 20-30 minutes is considered safe, especially when perfusion is compromised.
Do not give an IV insulin bolus.
Start continuous IV regular insulin 1-2 hours after fluids begin.
Typical insulin dose: 0.05-0.1 units/kg/hour. Many pediatric protocols start with 0.05 units/kg/hour.
Check potassium early and repeatedly. Hold insulin if potassium is severely low until potassium replacement is underway.
Add dextrose when glucose falls, but continue insulin until ketosis/acidosis resolves.
Monitor neurological status closely and treat suspected cerebral injury immediately with mannitol or hypertonic saline. Do not delay treatment for CT.
Avoid routine bicarbonate.

The Canadian statement specifically supports an initial 10-20 mL/kg isotonic fluid bolus as safe and desirable in pediatric DKA, rather than overly restrictive early fluid strategies (CPS guidance).

Recent evidence note: a 2025 systematic review on fluid therapy in pediatric DKA is available as PMID 41075988, and a 2024 systematic review is PMID 38572835. The evidence does not establish a single best fluid type or rate, which is why local pediatric protocols remain necessary.

Create a one-page pediatric DKA bedside algorithm

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mkdir -p "/tmp/workspace/pediatric-dka-bedside-algorithm/src" "/tmp/workspace/pediatric-dka-bedside-algorithm/output" && python - <<'PY' from reportlab.lib.pagesizes import A4 from reportlab.pdfgen import canvas from reportlab.lib import colors from reportlab.pdfbase.pdfmetrics import stringWidth from reportlab.lib.units import mm from reportlab.pdfbase.ttfonts import TTFont from reportlab.pdfbase import pdfmetrics from reportlab.pdfbase.pdfmetrics import stringWidth from textwrap import wrap out='/tmp/workspace/pediatric-dka-bedside-algorithm/output/Pediatric_DKA_Bedside_Algorithm.pdf' W,H=A4 c=canvas.Canvas(out,pagesize=A4) c.setTitle('Pediatric DKA Bedside Algorithm') # Palette NAVY=colors.HexColor('#123047'); BLUE=colors.HexColor('#1565A8'); PALE=colors.HexColor('#EAF4FA') GREEN=colors.HexColor('#167A53'); GREENPALE=colors.HexColor('#E9F7F0') ORANGE=colors.HexColor('#B95C00'); ORANGEPALE=colors.HexColor('#FFF2E3') RED=colors.HexColor('#B3261E'); REDPALE=colors.HexColor('#FDECEA') DARK=colors.HexColor('#17212B'); GREY=colors.HexColor('#4D5D6C'); LINE=colors.HexColor('#C7D5DE') M=10*mm contentW=W-2*M def rect(x,y,w,h,fill,stroke=None,r=0): c.setFillColor(fill) c.setStrokeColor(stroke or fill) c.roundRect(x,y,w,h,r,fill=1,stroke=1 if stroke else 0) def text(x,y,s,size=7.2,font='Helvetica',color=DARK): c.setFillColor(color); c.setFont(font,size); c.drawString(x,y,s) def bold(x,y,s,size=7.2,color=DARK): text(x,y,s,size,'Helvetica-Bold',color) def lines(x,y,arr,size=7,leading=8.5,font='Helvetica',color=DARK): c.setFillColor(color); c.setFont(font,size) yy=y for s in arr: c.drawString(x,yy,s); yy-=leading return yy def wrap_draw(x,y,w,s,size=7,leading=8.2,font='Helvetica',color=DARK,bullet=False): c.setFont(font,size); c.setFillColor(color) # simple width wrapping words=s.split(); arr=[]; cur='' for wd in words: test=(cur+' '+wd).strip() if stringWidth(test,font,size)<=w-(8 if bullet else 0): cur=test else: arr.append(cur); cur=wd if cur: arr.append(cur) yy=y for i,line in enumerate(arr): c.drawString(x+(7 if bullet else 0),yy,line) if bullet and i==0: c.circle(x+2,yy+2,1.15,fill=1,stroke=0) yy-=leading return yy def header(title, x, y, w, color): rect(x,y,w,6.5*mm,color,r=2*mm) bold(x+3.2*mm,y+2.15*mm,title,8.2,colors.white) def box(x,y,w,h,fill=colors.white): rect(x,y,w,h,fill,LINE,2*mm) # header rect(0,H-23*mm,W,23*mm,NAVY) bold(M,H-11.5*mm,'PEDIATRIC DIABETIC KETOACIDOSIS (DKA)',15,colors.white) text(M,H-17.5*mm,'BEDSIDE ALGORITHM | Child or adolescent with hyperglycemia, ketosis and acidosis',7.7,'Helvetica',colors.HexColor('#D7EAF7')) # Red alert rect(W-61*mm,H-19.2*mm,51*mm,8.2*mm,RED,r=2*mm) bold(W-58.5*mm,H-16.1*mm,'EMERGENCY: senior + PICU early',7.1,colors.white) # definition band Y=H-30*mm box(M,Y-11*mm,contentW,10*mm,PALE) bold(M+3*mm,Y-4.5*mm,'DKA:',7.5,BLUE) text(M+13*mm,Y-4.5*mm,'glucose >11 mmol/L (>200 mg/dL) + beta-hydroxybutyrate >=3 mmol/L (or moderate/large urine ketones)',7.1) text(M+13*mm,Y-8*mm,'+ venous pH <7.30 or HCO3 <18 mmol/L. Severe: pH <7.10 or HCO3 <5 mmol/L.',7.1) # Dimensions two column left=M; gap=5*mm; col=(contentW-gap)/2; right=left+col+gap cur=Y-15*mm # LEFT 1 initial h=40*mm; box(left,cur-h,col,h); header('1 FIRST 10 MINUTES: ABCDE + PREPARE',left,cur-6.5*mm,col,BLUE) y=cur-10*mm for s in [ 'Weigh child. Cardiorespiratory monitor; 2 IV lines if possible.', 'Assess perfusion, BP, GCS/behavior, headache, vomiting, work of breathing.', 'If impaired consciousness: protect airway; consider NG tube if vomiting/coma.', 'Blood: glucose, ketones, VBG, Na/K/Cl/HCO3, urea/creatinine, Ca/Mg/PO4; ECG if K abnormal.', 'Look for trigger: new T1D, missed insulin/pump failure, infection, psychosocial cause.' ]: y=wrap_draw(left+3*mm,y,col-6*mm,s,6.7,7.5,bullet=True) cur-=h+4*mm # left 2 fluids h=47*mm; box(left,cur-h,col,h); header('2 FLUIDS: ISOTONIC, CALCULATED, 48 h',left,cur-6.5*mm,col,GREEN) y=cur-10*mm bold(left+3*mm,y,'IF SHOCK / POOR PERFUSION',6.8,RED); y-=3.5*mm y=wrap_draw(left+3*mm,y,col-6*mm,'0.9% sodium chloride (or approved balanced isotonic crystalloid) 10 mL/kg over 15-30 min; reassess. Further bolus only with senior/PICU review.',6.7,7.5,bullet=True) y-=1.4*mm bold(left+3*mm,y,'IF NOT SHOCKED',6.8,GREEN); y-=3.5*mm y=wrap_draw(left+3*mm,y,col-6*mm,'Use actual admission weight. Use local calculator: maintenance + estimated deficit, usually over 48 h. Follow local policy for whether routine bolus is subtracted.',6.7,7.5,bullet=True) y=wrap_draw(left+3*mm,y,col-6*mm,'Typical deficit estimate: 5% if pH >=7.1; 10% if pH <7.1. Avoid hypotonic fluid initially.',6.7,7.5,bullet=True) y=wrap_draw(left+3*mm,y,col-6*mm,'Strict input/output. Review corrected Na and perfusion serially. Escalate if rising urea, oliguria, shock, or neurologic concern.',6.7,7.5,bullet=True) cur-=h+4*mm # left 3 potassium h=47*mm; box(left,cur-h,col,h); header('3 POTASSIUM: CHECK BEFORE INSULIN',left,cur-6.5*mm,col,ORANGE) y=cur-10*mm for title,body in [ ('K+ <3.0 mmol/L','Hold insulin. Urgent K replacement with ECG monitoring and senior/PICU input.'), ('K+ 3.0-5.5 mmol/L','Start K in IV fluid once urine output and renal function are satisfactory. Common total concentration: 40 mmol/L, but use local protocol.'), ('K+ >5.5 mmol/L','Do not add K initially. Check frequently; add once K falls and urine output is established.')]: bold(left+3*mm,y,title,6.8,ORANGE); y-=3.2*mm y=wrap_draw(left+3*mm,y,col-6*mm,body,6.55,7.25,bullet=True); y-=1.1*mm # right 1 insulin cur=Y-15*mm h=41*mm; box(right,cur-h,col,h); header('4 INSULIN: START AFTER FLUIDS',right,cur-6.5*mm,col,BLUE) y=cur-10*mm for s in [ 'Begin IV regular/soluble insulin 1-2 h after IV fluids start, only when K+ is safe.', 'NO IV insulin bolus.', 'Usual rate: 0.05 units/kg/h. Consider 0.1 units/kg/h only for severe DKA or per local protocol.', 'Example: 25 kg x 0.05 = 1.25 units/h. If 1 unit/mL infusion, run at 1.25 mL/h.', 'Continue insulin until ketoacidosis resolves, not merely until glucose normalizes.' ]: y=wrap_draw(right+3*mm,y,col-6*mm,s,6.7,7.5,bullet=True) cur-=h+4*mm # right dextrose h=32*mm; box(right,cur-h,col,h); header('5 GLUCOSE FALLING? ADD DEXTROSE, DO NOT STOP INSULIN',right,cur-6.5*mm,col,GREEN) y=cur-10*mm for s in [ 'When glucose reaches about 14-17 mmol/L (250-300 mg/dL), add 5% dextrose to isotonic fluid.', 'If glucose continues to fall or is <8-10 mmol/L while ketosis persists, increase to 10% dextrose per protocol.', 'Expected glucose decline: about 3-5 mmol/L/h (50-90 mg/dL/h).' ]: y=wrap_draw(right+3*mm,y,col-6*mm,s,6.7,7.5,bullet=True) cur-=h+4*mm # right monitoring h=35*mm; box(right,cur-h,col,h); header('6 MONITOR AND TARGET',right,cur-6.5*mm,col,ORANGE) y=cur-10*mm for s in [ 'Hourly: glucose, vital signs, GCS/neurologic status, fluid balance, infusion checks.', 'Every 1-2 h initially: VBG, Na/K/Cl/HCO3, ketones where available; then per local protocol.', 'Goals: clinical improvement, closing anion gap, rising HCO3, falling ketones. Corrected Na should not fall unexpectedly.' ]: y=wrap_draw(right+3*mm,y,col-6*mm,s,6.65,7.4,bullet=True) cur-=h+4*mm # right resolution h=31*mm; box(right,cur-h,col,h); header('7 RESOLUTION AND TRANSITION',right,cur-6.5*mm,col,GREEN) y=cur-10*mm for s in [ 'Resolve when clinically well and pH >7.30, HCO3 >=15-18 mmol/L, anion gap closed and ketones resolving.', 'Give SC rapid-acting insulin 15-30 min before stopping IV insulin. Ensure basal-insulin overlap as per local regimen.' ]: y=wrap_draw(right+3*mm,y,col-6*mm,s,6.65,7.4,bullet=True) # red emergency lower bar Y2=20*mm box(M,Y2,contentW,24*mm,REDPALE) header('RED FLAGS: SUSPECT CEREBRAL INJURY - TREAT IMMEDIATELY, DO NOT WAIT FOR CT',M,Y2+17.5*mm,contentW,RED) y=Y2+14*mm bold(M+3*mm,y,'Signs:',6.8,RED); text(M+14*mm,y,'new/worsening headache, repeated vomiting, irritability/confusion, decreasing GCS, seizure, bradycardia + hypertension, abnormal breathing.',6.55) y-=4.1*mm bold(M+3*mm,y,'Actions:',6.8,RED); text(M+15*mm,y,'call PICU, elevate head 30°, head midline, reduce fluid to minimum needed for perfusion; give mannitol 0.5-1 g/kg IV over 10-15 min',6.55) y-=3.4*mm text(M+15*mm,y,'OR 3% hypertonic saline 2.5-5 mL/kg IV over 10-15 min. Prepare controlled airway support. Image after initial treatment/stabilization.',6.55) # Footer text(M,8*mm,'For trained clinicians only. Use alongside your institution-approved pediatric DKA order set/calculator. Do not use for HHS or mixed DKA-HHS without specialist input.',5.7,'Helvetica',GREY) text(M,5*mm,'Sources: ISPAD 2022 DKA/HHS guideline; BSPED DKA guideline (resource page updated Nov 2024); Canadian Paediatric Society DKA recommendations.',5.5,'Helvetica',GREY) text(W-M-50*mm,5*mm,'Prepared: 01 Sep 2026',5.5,'Helvetica',GREY) c.showPage(); c.save() print(out) PY

Running Command

python - <<'PY' from pypdf import PdfReader p='/tmp/workspace/pediatric-dka-bedside-algorithm/output/Pediatric_DKA_Bedside_Algorithm.pdf' r=PdfReader(p) print('pages=', len(r.pages)) print('size=', __import__('os').path.getsize(p)) print('text_chars=', len(r.pages[0].extract_text() or '')) PY

Reading File

Created and verified as a single-page, print-ready bedside algorithm.

Pediatric DKA Bedside Algorithm

PDF Document · PDF

It includes immediate assessment, isotonic fluid guidance, potassium thresholds, insulin infusion rates, dextrose adjustment, monitoring, DKA resolution, and emergency cerebral-injury treatment. It is designed to be used with local pediatric DKA orders and calculator.

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