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Diabetic Ketoacidosis Protocol

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

Diabetic ketoacidosis (DKA) protocol 2019 revision now available

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 has updated the BCCH DKA Protocol. Our 2019 revision aligns closely with the DKA protocol developed by 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. The 2019 revision is also aligned with the Clinical Practice Consensus Guidelines 2022 of the International Society for Pediatric and Adolescent Diabetes (ISPAD).


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 (2021/02/09 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.

Slide Set

We have made available a slide set for use with presenting the BCCH DKA Protocol 2019 revision to other professionals:


In conjunction with Child Health BC, we have produced a webcast discussing the new BCCH DKA Protocol, available here.

Modifications to the 2019 protocol

The major modifications from the previous version (dated 2015/10/07) of the protocol include:

  • more-aggressive fluid boluses are suggested at the start of therapy: all patients with DKA should receive a 10-mL/kg bolus of normal saline at the beginning, and the majority will receive a second 10-mL/kg bolus to follow
  • fluid infusion rate calculations have been simplified
  • fluid rehydration rates will reflect a goal to correct losses over a 36-h period (previously this was 48 h)

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 BCCH 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 (>33.3 mmol/L) and effective serum osmolality (>320 mOsm/L) without significant ketosis or acidosis (arterial pH >7.30, venous pH >7.25, bicarbonate >15 mmol/L). Obtundation, combativeness, or seizures occur in approximately 50% of patients. 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 (ISPAD) 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: Diabetic Ketoacidosis Protocol ( )
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