Diabetic Ketoacidosis (DKA) & Hyperosmolar Hyperglycaemic State (HHS)

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• DKA resolution is defined by KETONE clearance — the intravenous insulin infusion continues until ketonaemia resolves, not until glucose normalises; stopping early leaves the ketoacidosis untreated (a named management pitfall).
• Address potassium before or with insulin — current guidance runs continuous IV insulin only once fluid status is restored and potassium levels have been achieved; hypokalaemia was common enough under the previous UK regimen to help drive the 2022 JBDS rewrite.
• Once glucose falls under 14 mmol/L, do NOT stop insulin — start a 5% or 10% glucose infusion (JBDS HHS pathway) and consider de-escalating the DKA infusion from 0.1 to 0.05 units/kg/h (JBDS DKA update).
• Routine bicarbonate is discouraged — it can worsen ketosis and hypokalaemia and carries cerebral-oedema risk (bicarbonate treatment was associated with cerebral oedema in children, relative risk 4.2). Consider IV bicarbonate only if pH falls below 6.9, or peri-intubation with pH below 7.2 and bicarbonate below 10 mEq/L.
• Cerebral oedema is the devastating complication of DKA in children — independently associated with lower initial PaCO2 (severity of acidosis), higher urea nitrogen (dehydration) and bicarbonate treatment.
• HHS is a high-mortality emergency (pooled mortality 21.1 per cent, roughly ten times DKA) — VTE prevention is a named pathway aim; let osmolality fall gradually (3.0-8.0 mOsm/kg/h JBDS, under 3 mOsm/kg/h ADA).