Are intensive care settings essential in the management of diabetic ketoacidosis in children?

PURPOSE: Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes in children and is frequently managed in pediatric intensive care units (PICUs). This study aimed to evaluate the feasibility and safety of managing DKA in the pediatric emergency department (PED). METHODS: A retrospective analysis was conducted of pediatric patients presenting with DKA between 2017 and 2024 at a tertiary care hospital. Patients were categorized according to DKA severity and evaluated for demographic characteristics, risk factors, clinical findings, laboratory parameters, complications, and outcomes. All patients were managed using a standardized institutional treatment protocol. Clinical characteristics of patients admitted to the PICU were compared with those managed in the PED. RESULTS: A total of 169 patients were included (mean age, 10.3 ± 4.4 years). Most patients were managed in the PED until resolution of DKA (95.3%). Moderate and severe DKA accounted for 71% of cases. Complications occurred in 27 patients (15.9%). Although tachycardia, respiratory abnormalities, decreased Glasgow Coma Scale scores (≤14), and electrolyte abnormalities were more frequent among patients admitted to the PICU, most patients with these findings were successfully managed in the PED. Patients requiring PICU admission had significantly lower pH levels, lower bicarbonate concentrations, more frequent neurologic impairment, and a higher rate of electrolyte abnormalities. CONCLUSION: Most pediatric patients with DKA can be safely managed outside the PICU when standardized protocols and close clinical monitoring are implemented. A selective PICU admission strategy based on clinical indicators of deterioration may therefore help optimize the use of limited intensive care resources while maintaining patient safety.