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DKA Protocol

The BC Children's Hospital diabetic ketoacidosis (DKA) protocol has now been revised.


Following the publication of the PEKARN DKA FLUID Trial [New Engl J Med 2018;378(24):2275–2287], which demonstrated the safety of more aggressive fluid replacement regimens than are used in current DKA protocols, the Division of Pediatric Endocrinology & Diabetes is in the process of updating the BCCH DKA Protocol. It will align closely with the protocol developed by the TREKK (Translating Emergency Knowledge for Kids), which is designed for the initial management of pediatric DKA in most Canadian emergency departments, as well as with the DKA algorithm developed by the Canadian Pediatric Endocrine Group, which is designed for ongoing inpatient management of DKA.

We hope to have our revised protocol available online by April 2019. In the meantime, the current 2015 protocol is still considered safe and consistent with treatment used in the PECARN DKA FLUID Trial.

The BC Children's Hospital diabetic ketoacidosis (DKA) protocol has now been revised to conform to the ISPAD's Clinical Practice Consensus Guidelines 2018 and the related 2011 Global IDF/ISPAD Guideline for Diabetes in Childhood and Adolescence (see below). If you have any queries related to the management of DKA in children, please contact the Pediatric Endocrinologist on call.

The protocol and accompanying documents can be downloaded in a single document, the DKA Protocol Toolkit, or as individual documents:

Fillable pdf

The DKA Medical Protocol can also be downloaded in fillable PDF format (2016/09/05 version). This version auto-calculates the fluid rates and has some pop-up screens to guide in the clinical evaluation of children presenting with DKA.

Modifications to the 2006/2015 protocol

The major modifications from the previous version (dated 2006/11/03) of the protocol include:

  • increased caution in the use of hypotonic fluids in the first 12–24 hours of DKA management
  • reinforcement of the pre-treatment need to assess the level of dehydration and extracellular volume contraction using e.g. hematocrit
  • increased attention to serum sodium levels and the appreciation of the coexistence of hypernatremic dehydration and/or the hyperglycemic hyperosmolar state with DKA
  • delay in the introduction of insulin infusions for the first 1–2 hours of DKA management
  • formalization of the use of the “ two-bag system” [J Peds 1999;134(3):376-378] to facilitate physician and nursing management of IV fluids
  • in October 2015, broadening of the safe and effective range of 0.05–0.1 units/kg/h for the insulin infusion

The changes were introduced to reflect an increased understanding in the medical literature of factors leading to complications, particularly cerebral edema, which arise during the treatment of DKA in infants, children and adolescents.

There is also an accompanying article entitled Diabetic Ketoacidosis in Children and Adolescents: An Update and Revised Treatment Protocol in the January/February 2010 issue of the British Columbia Medical Journal describing the protocol and the management of DKA in children in more detail.

We hope that you will find these materials to be helpful in managing pediatric cases of diabetic ketoacidosis. Please do not hesitate to contact the Endocrinology & Diabetes Unit at BC Children's Hospital for any help in implementing this protocol at your health-care centre in British Columbia. We also welcome any suggestions to make this material more useful to your practice.

Protocols & consensus statements online

Hyperglycemic hyperosmolar syndrome

This should be suspected when there are significant elevations in the blood glucose (>33 mmol/L) and osmolality (>330 mOsm/L) without significant ketosis or acidosis (bicarbonate >15 mmol/L). HHS is more likely in type 2 diabetes, or in type 1 diabetes when the patient has been consuming large quantities of glucose-containing drinks. Some patients can present with a mixed picture of both HHS and DKA. HHS is associated with more serious volume depletion, and the management of HHS differs from that of DKA. Both the Pediatric Endocrine Society and the International Society for Pediatric and Adolescent Diabetes have published guidelines for the management of HHS.


The following information, i.e. guideline/educational material/policy or procedure, has been developed for use only within BC Children’s Hospital. There are support systems at BC Children’s Hospital that may not exist in other clinical settings and therefore any adoption of these materials cannot be the responsibility of BC Children’s. Agencies other than BC Children’s Hospital should use this information as a guideline for reference purposes only. All materials are the property of BC Children’s Hospital and may only be reprinted in whole or in part with our expressed permission.

SOURCE: DKA Protocol ( )
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