What is the most appropriate initial therapy for a patient with diabetic ketoacidosis (DKA), hyperglycemia, and dehydration?

Management of Diabetic Ketoacidosis in a 10-Year-Old with Type 1 Diabetes

A bolus of normal saline is the most appropriate initial therapy for this 10-year-old girl presenting with diabetic ketoacidosis (DKA), as fluid resuscitation must precede insulin therapy to prevent complications. 1

Clinical Assessment

This patient presents with classic signs of DKA:

• Comatose state with deep, labored respirations (Kussmaul breathing)
• History of type 1 diabetes
• Pale, dry mucous membranes indicating dehydration
• Tachycardia (HR 124/min) and hypotension (BP 90/41 mmHg)
• Laboratory findings consistent with DKA:
  • pH 7.21 (acidosis)
  • Low bicarbonate (11 mEq/L)
  • Hyperglycemia (250 mg/dL)
  • Increased base deficit (-9 mEq/L)

Treatment Algorithm

1. Initial Fluid Resuscitation (FIRST PRIORITY)

• Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour initially 1
• This addresses the severe dehydration and hypotension before insulin administration
• Fluid resuscitation helps improve tissue perfusion and renal function

2. Insulin Therapy (Start AFTER initial fluid resuscitation)

• Initiate insulin therapy 1-2 hours after starting fluid replacement 1
• Continuous intravenous insulin infusion at 0.1 U/kg/hour 2, 1
• Do NOT administer an initial insulin bolus in pediatric patients 2, 1
• Goal: Decrease blood glucose by 50-75 mg/dL per hour 2

3. Electrolyte Management

• Begin potassium replacement once serum levels fall below 5.5 mEq/L and adequate urine output is confirmed 2
• Add 20-30 mEq potassium (2/3 KCl and 1/3 KPO4) per liter of IV fluid 2, 1
• Monitor potassium closely as insulin therapy will drive potassium into cells

4. Bicarbonate Therapy

• Not indicated in this patient with pH > 7.0 2
• Only consider bicarbonate if pH < 6.9 2, 1

5. Monitoring

• Blood glucose every 1-2 hours
• Electrolytes, BUN, creatinine every 2-4 hours
• Venous pH and anion gap every 2-4 hours
• Continuous cardiac monitoring for T-wave changes (indicating hypo/hyperkalemia)
• Neurological status for signs of cerebral edema

Rationale for Normal Saline as Initial Therapy

1. The patient shows signs of significant dehydration and hypotension, which must be addressed first 1
2. Insulin administration without adequate fluid resuscitation can worsen hypotension and potentially precipitate shock 2
3. Guidelines specifically state that fluid resuscitation should precede insulin therapy by 1-2 hours in pediatric DKA 1
4. Other options are inappropriate:
   • Calcium gluconate: Not indicated in DKA management
   • Thiamine: Not a priority in DKA management
   • Activated charcoal: Used for toxin ingestion, not DKA
   • NPH insulin: Long-acting insulin is inappropriate for acute DKA management

Common Pitfalls to Avoid

1. Administering insulin before adequate fluid resuscitation: This can worsen hypotension and potentially precipitate shock
2. Giving an insulin bolus: Bolus insulin is contraindicated in pediatric DKA patients 2, 1
3. Rapid fluid administration: Too aggressive fluid replacement increases risk of cerebral edema, especially in children 2
4. Inadequate monitoring: Close monitoring of clinical and laboratory parameters is essential to detect complications early
5. Failure to investigate precipitating factors: In this case, Halloween night suggests possible dietary indiscretion

Transition to Subcutaneous Insulin

Once DKA is resolved (glucose <200 mg/dL, bicarbonate ≥18 mEq/L, pH >7.3), transition to subcutaneous insulin can begin, with continuation of IV insulin for 1-2 hours after the first subcutaneous dose 1.

Following resolution of the acute episode, the patient will require education on sick day management and strategies to prevent future DKA episodes.