When should I consider transferring a patient with DKA to a higher level of care, such as an intensive care unit?

When considering transferring a patient with diabetic ketoacidosis (DKA) to a higher level of care, such as a high-dependency unit (HDU) or intensive care unit (ICU), the following criteria apply primarily to children and young people, as per the provided guidelines:

• Immediate transfer to a high-dependency unit (preferably paediatric) or a general paediatric ward with one-to-one nursing should be considered if the child or young person is younger than 2 years or has severe DKA (blood pH below 7.1) NICE NG18.
• Urgent anaesthetic review and discussion with a paediatric critical care specialist are necessary if a child or young person with DKA cannot protect their airway due to a reduced level of consciousness NICE NG18. This indicates a need for higher-level care.
• Discussion with a paediatric critical care specialist is required if a child or young person with DKA is in hypotensive shock, to consider the use of inotropes NICE NG18. This also points to the need for critical care.
• If cerebral oedema is suspected or treatment has begun (with mannitol or hypertonic sodium chloride), immediate specialist advice on further management, including the best care setting, should be sought NICE NG18.
• For hypokalaemia (potassium below 3 mmol/litre), urgent discussion with a paediatric critical care specialist is needed, especially if intravenous potassium solutions above 40 mmol/litre are required via a central venous catheter NICE NG18.

All children and young people with DKA should be cared for in a facility capable of providing the necessary level of monitoring and care for DKA NICE NG18. Those under 2 years or with severe DKA (blood pH below 7.1) are at an increased risk of cerebral oedema and require monitoring of consciousness and heart rate every 30 minutes NICE NG18.