DKA - fluid therapy in children (ED focus)
This section summarises the UK paediatric approach to intravenous fluid management in children and young people with diabetic ketoacidosis (DKA).
It emphasises immediate recognition and treatment of shock, cautious protocolised rehydration to minimise the risk of cerebral oedema, routine potassium replacement, timed insulin infusion, frequent monitoring and early escalation to paediatric/PICU care (NICE NG18).
Use this alongside local paediatric DKA protocols and early senior advice.
Key principles
- Treat shock immediately with 10 ml/kg isotonic boluses and reassess after each bolus; resuscitation boluses for shock are not subtracted from the DKA deficit.
- For non‑shocked children who need IV fluids, give 10 ml/kg 0.9% sodium chloride over 30 minutes and subtract this initial non‑resuscitative bolus from the calculated deficit.
- Replace the estimated fluid deficit slowly over 48 hours in addition to maintenance fluids calculated by Holliday-Segar.
- Use 0.9% sodium chloride (no glucose) until plasma glucose is < 14 mmol/L; then change to glucose‑containing fluids to allow continued insulin infusion without hypoglycaemia.
- Add potassium to ongoing fluids (standard 40 mmol/L) unless the patient is anuric or hyperkalaemic; monitor and replace potassium promptly.
- Start IV insulin 1-2 hours after beginning IV fluids (do not give an insulin bolus) at 0.05-0.1 U/kg/h; stop insulin if serum K+ < 3.0 mmol/L.
- Monitor clinical state, fluid balance, capillary glucose...
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