Confirm DKA and grade severity
ISPAD 2022 defines DKA as glucose over 200 mg/dL (11 mmol/L), venous pH under 7.3 or bicarbonate under 18, and beta-hydroxybutyrate (BOHB) 3 mmol/L or more, or moderate to large urine ketones. If pH is 7.3 or more and bicarbonate 18 or more, it is hyperglycemia or ketosis without acidosis, not DKA.
Grade severity by the worst venous pH or bicarbonate. Severity sets the assumed fluid deficit used in the calculation.
| Severity | Venous pH or bicarbonate | Assumed deficit |
|---|---|---|
| Mild | pH under 7.3 or HCO3 under 18 | 5% |
| Moderate | pH under 7.2 or HCO3 under 10 | 7% |
| Severe | pH under 7.1 or HCO3 under 5 | 10% |
Step 1: the fluid bolus
Give 0.9% saline 10–20 mL/kg IV over 20–30 minutes in a dehydrated child who is not in shock. Use 20 mL/kg if peripheral perfusion is poor. In shock, give 20 mL/kg boluses as fast as possible through a large-bore line, reassessing after each, until circulation is restored. Each bolus is capped at 1,000 mL.
Before anything else: weigh the child, place two IV lines and a cardiac monitor, and do neuro checks at least hourly.
Step 2: deficit plus maintenance over 24–48 hours
Use 0.45–0.9% saline or Ringer's lactate. The assumed deficit in mL is the percentage times weight in kg times 1,000. Subtract the bolus already given, then spread the remainder evenly over 24 to 48 hours and add hourly maintenance. ISPAD's 5–10% deficit range matches the PECARN FLUID trial. Do not add urine losses routinely.
Maintenance uses Holliday–Segar: 4 mL/kg/h for the first 10 kg, 2 mL/kg/h for the next 10 kg, and 1 mL/kg/h for each kg above 20.
Hourly rate = maintenance + (deficit − bolus) ÷ 24 to 48 hours.
Worked example: 20 kg child with moderate DKA
A 20 kg child has moderate DKA, is dehydrated but not in shock, and has potassium 3.0–5.5 mmol/L. The numbers below follow the same rules as the calculator.
| Step | Calculation | Result |
|---|---|---|
| Bolus | 10 mL/kg × 20 kg, over 20–30 min | 200 mL |
| Assumed deficit | 7% × 20 kg × 1,000 | 1,400 mL |
| Deficit after bolus | 1,400 − 200 | 1,200 mL |
| Maintenance | 40 + (2 × 10) mL/h | 60 mL/h |
| Rate over 24 h | 60 + 1,200 ÷ 24 | 110 mL/h |
| Rate over 48 h | 60 + 1,200 ÷ 48 | 85 mL/h |
| Insulin infusion | 0.05–0.1 units/kg/h | 1–2 units/h |
| Potassium | 40 mmol/L in fluid; max 0.5 mmol/kg/h | Up to 10 mmol/h |
Insulin, potassium and dextrose
Insulin: regular insulin infusion 0.05–0.1 units/kg/h IV, started at least 1 hour after fluids began, with no bolus; 0.05 can be considered if pH is over 7.15. If an IV infusion is not possible, uncomplicated mild or moderate DKA with good perfusion can be treated with subcutaneous lispro or aspart 0.15 units/kg every 2 hours, starting 1 hour after fluids began.
Potassium: with potassium 3.0–5.5 mmol/L, add 40 mmol/L from the start of deficit replacement, at no more than 0.5 mmol/kg/h. Below 3.0, hold insulin and give potassium first on a cardiac monitor. Above 5.5, or before urine output, start with potassium-free fluid and add potassium once urine output is documented and potassium is under 5.5.
Dextrose: add 5% dextrose when glucose reaches 250–300 mg/dL (14–17 mmol/L), or sooner if it falls faster than 90 mg/dL per hour. Use 10% or 12.5% if needed. Never stop insulin while the child is still acidotic. No bicarbonate except for life-threatening hyperkalemia, or pH under 6.9 with impaired cardiac contractility.
Monitoring, cerebral injury and resolution
Check glucose hourly, venous pH and BOHB every 2 hours, and electrolytes every 2–4 hours. Keep mannitol 20% (0.5–1 g/kg over 10–15 minutes) or 3% saline (2.5–5 mL/kg) at the bedside; draw it up if several risk factors are present: BUN over 20 mg/dL, pH under 7.1, PCO2 under 21 mm Hg, or age under 5 years. For the 20 kg child, that is 10–20 g of mannitol or 50–100 mL of 3% saline.
DKA has resolved when pH is over 7.30, bicarbonate over 18 and BOHB under 1 mmol/L (or the anion gap has closed). Give the first subcutaneous rapid-acting dose 15–30 minutes before stopping the infusion, with basal insulin.
Use the free tool
Diagnosis, fluids, insulin, potassium, dextrose and cerebral edema rescue doses.
Open DKA →Common questions
What deficit should I assume in pediatric DKA?
The calculator follows ISPAD 2022's 5–10% range: 5% for mild, 7% for moderate and 10% for severe DKA, graded by the worst venous pH or bicarbonate.
Do I subtract the bolus from the DKA deficit?
Yes. Subtract the bolus volume from the assumed deficit, then replace the remainder evenly over 24–48 hours on top of Holliday–Segar maintenance. Urine losses are not added routinely.
When do I start insulin in pediatric DKA?
At least 1 hour after fluids begin, as a regular insulin infusion at 0.05–0.1 units/kg/h with no bolus. If potassium is under 3.0 mmol/L, hold insulin and replace potassium first.
When do I add dextrose to DKA fluids?
Add 5% dextrose when glucose reaches 250–300 mg/dL (14–17 mmol/L), or sooner if it falls faster than 90 mg/dL per hour. Use 10% or 12.5% dextrose if needed rather than stopping insulin.
Sources
Glaser N, Fritsch M, Priyambada L, et al. ISPAD Clinical Practice Consensus Guidelines 2022: diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes 2022;23(7):835–856.
For education only, not medical advice. Always confirm against current guidelines and your local protocols. Pedemy is independent and not affiliated with or endorsed by the organizations cited.