ISPAD Issues Consensus Statement on Diabetic Ketoacidosis and Hyperglycemia

sealed drip bag
sealed drip bag
ISPAD recommends adjustments for fluid management regarding rehydration rates in children and adolescents with diabetes ketoacidosis.

A new consensus statement from the International Society for Pediatric and Adolescent Diabetes (ISPAD) modifies recommendations about fluid management in young patients with a diagnosis of diabetic ketoacidosis (DKA).

These modifications reflect the results of a randomized controlled clinical trial that demonstrated no difference in cerebral injury in patients rehydrated at different rates with either 0.45% or 0.9% saline. The full consensus report has been published in Pediatric Diabetes.

The new ISPAD recommendations are based on currently available evidence and intended to be a general guide to managing DKA. The guideline authors emphasize that “clinical judgment should always be used to determine optimal treatment for the individual patient.”

Key recommendations include:

  • Emergency assessment should follow the general guidelines for Pediatric Advanced Life Support (PALS)
  • Management should be conducted in a center that is experienced in treating DKA in children/adolescents
  • Fluid replacement should begin prior to initiation of insulin therapy
  • Insulin therapy should begin with 0.05-0.1 U/kg/hour at least 1 hour after beginning fluid replacement therapy
  • In hyperkalemic patients, potassium replacement therapy should be deferred until urine output is documented
  • Bicarbonate is not recommended unless life-threatening hyperkalemia or unusually severe acidosis (vpH <6.9) with evidence of compromised cardiac contractility is present
  • Patients with multiple risk factors for cerebral edema should have mannitol or hypertonic saline at the bedside with the appropriate dose calculated

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In patients in a hyperglycemic hyperosmolar state, the goals of initial fluid therapy are to expand intra- and extravascular volume, restore normal renal perfusion, and promote a gradual decline in corrected serum sodium concentration and serum osmolality. The ISPAD guidelines also recommend beginning the administration of insulin at a dose of 0.025 to 0.05 U/kg/hour after plasma glucose levels are below 3 mmol/L per hour with only fluid.


Wolfsdorf JI, Glaser N, Agus M, et al. Diabetic ketoacidosis and hyperglycemic hyperosmolar state: a consensus statement from the international society for pediatric and adolescent diabetes [published online June 13, 2018]. Pediatr Diabetes. doi:10.1111/pedi.12701