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.”

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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