Treatment of Diabetic Ketoacidosis in Children
The treatment of diabetic ketoacidosis (DKA) in children requires immediate fluid resuscitation with isotonic saline, followed by insulin therapy at 0.1 units/kg/hour, with careful monitoring of electrolytes and gradual correction of acidosis to prevent cerebral edema. 1, 2
Diagnostic Criteria for DKA in Children
- Blood glucose >250 mg/dL
- Venous pH <7.3
- Bicarbonate <15 mEq/L
- Presence of ketones in blood or urine 1
Initial Management
Fluid Resuscitation
- Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour for the first 1-2 hours to address dehydration and hypotension 1
- After initial bolus, calculate fluid deficit and provide rehydration over 48 hours 3
- Use isotonic solutions initially; subsequent fluid management should be with at least 0.45% saline 3
- When glucose reaches 250 mg/dL, add 5-10% dextrose to IV fluids while continuing insulin to clear ketones 1
Insulin Therapy
- Start insulin 1-2 hours after beginning fluid replacement 1, 2
- Use continuous IV insulin infusion at 0.1 units/kg/hour 1, 3
- Target glucose decline of 50-75 mg/dL per hour 1
- If glucose doesn't fall by 50 mg/dL in first hour, double insulin infusion rate hourly until achieving steady decline 1
- When glucose reaches 250 mg/dL, reduce insulin to 0.05-0.1 units/kg/hour and add dextrose to IV fluids 1
Electrolyte Management
Potassium Replacement
- Begin potassium replacement when serum levels fall below 5.5 mEq/L and adequate urine output is confirmed 2
- Use 20-30 mEq potassium (2/3 KCl and 1/3 KPO₄) in each liter of infusion fluid 2
- If hypokalemia is present at diagnosis, start potassium replacement with fluid therapy and delay insulin until potassium is >3.3 mEq/L 2
Bicarbonate Therapy
- Not recommended if pH is >7.0 2, 1
- For pH 6.9-7.0, consider 50 mmol sodium bicarbonate diluted in 200 mL sterile water, infused at 200 mL/h 2
- For pH <6.9, consider 100 mmol sodium bicarbonate in 400 mL sterile water at 200 mL/h 2
Phosphate Replacement
- Consider phosphate replacement in patients with cardiac dysfunction, anemia, respiratory depression, or serum phosphate <1.0 mg/dL 2, 1
Monitoring During Treatment
- Blood glucose: Every 1-2 hours until stable 1
- Electrolytes, BUN, creatinine: Every 2-4 hours 1
- Venous pH and anion gap: To evaluate resolution of acidosis 1
- Neurological status: Frequent checks for signs of cerebral edema 4
- Serum ketones (preferably β-hydroxybutyrate): Until resolution 1
Complications to Watch For
Cerebral Edema
- Occurs in 0.5-0.9% of DKA episodes but is the major cause of death in childhood DKA 4
- Risk factors include severity of acidosis, greater hypocapnia, higher BUN at presentation, and bicarbonate treatment 3
- Warning signs: Headache, decreased mental status, irritability, abnormal pupillary responses, hypertension, bradycardia
- Treatment: Immediate administration of mannitol (0.5-1 g/kg) or hypertonic saline 1
Hyperchloremic Acidosis
- More common with faster fluid administration rates 5
- Monitor chloride levels during treatment
Resolution and Transition to Subcutaneous Insulin
DKA is considered resolved when:
- Blood glucose <200 mg/dL
- Serum bicarbonate ≥18 mEq/L
- Venous pH >7.3
- Normalized anion gap
- Patient is hemodynamically stable 1
After resolution:
- Transition to subcutaneous insulin
- Continue IV insulin for 1-2 hours after first subcutaneous dose 1
- For newly diagnosed type 1 diabetes, initiate multiple-dose insulin therapy 2
- For type 2 diabetes with resolved DKA, consider metformin while continuing subcutaneous insulin therapy 2
Prevention of Recurrent DKA
- Provide education on recognition and prevention of DKA
- Teach sick day management
- Ensure regular follow-up with healthcare providers 1
- Address insulin omission, which is the most common cause of recurrent DKA 6
The management of DKA in children requires careful attention to fluid and electrolyte balance, with the primary goal of preventing cerebral edema while correcting metabolic derangements.