What is the treatment guidance for pediatric patients with diabetic ketoacidosis (DKA)?

Pediatric Diabetic Ketoacidosis (DKA) Management

The management of pediatric DKA requires immediate intervention with fluid resuscitation, insulin therapy, electrolyte replacement, and careful monitoring to prevent complications such as cerebral edema, with fluid therapy administered over 48 hours rather than 36 hours to minimize risk of cerebral edema. 1

Diagnostic Criteria

• Blood glucose >250 mg/dL
• Arterial pH <7.3 or bicarbonate <15 mEq/L
• Moderate ketonuria or ketonemia

Severity Classification

Parameter	Mild	Moderate	Severe
Arterial pH	7.25-7.30	7.00-7.24	<7.00
Serum bicarbonate (mEq/L)	15-18	10-14	<10
Mental status	Alert	Alert/drowsy	Stupor/coma

Initial Assessment and Laboratory Workup

• Arterial blood gases
• Complete blood count with differential
• Urinalysis
• Blood glucose
• BUN, electrolytes, chemistry profile
• Creatinine
• ECG

Treatment Algorithm

1. Fluid Resuscitation

• Initial fluid: Normal saline (0.9% NaCl) at 4-14 ml/kg/hr 1
• First hour: Administer 1-1.5 L isotonic saline to restore circulatory volume
• For severe hypernatremia/hyperchloremia: Consider 0.45% NaCl at 4-14 ml/kg/hr
• Target correction rate: Not exceeding 3 mOsm/kg/hour decrease in serum osmolality
• Maximum correction: 10 mEq/L in first 24 hours
• Total fluid deficit replacement over 48 hours (not 36 hours) 1, 2

2. Insulin Therapy

• Start after initial fluid resuscitation
• Do not administer insulin bolus - this is an important update to previous protocols 1, 3
• Continuous IV infusion: Regular insulin at 0.1 U/kg/hour
• Delay insulin if initial potassium <3.3 mEq/L to avoid arrhythmias 1
• Continue insulin until resolution of metabolic acidosis

3. Potassium Replacement

• Begin once renal function is confirmed and urine output established
• Add 20-30 mEq/L potassium to IV fluids (2/3 KCl and 1/3 KPO₄) 1
• Target potassium: 4-5 mEq/L

4. Monitoring

• Hourly vital signs and neurological checks
• Hourly blood glucose monitoring
• Every 2-4 hours: Electrolytes, venous pH, bicarbonate, BUN, creatinine
• Strict input/output monitoring
• Cardiac monitoring for high-risk patients

Cerebral Edema Prevention and Management

Cerebral edema is the most serious complication with 1-3% mortality in pediatric DKA 4. Prevention strategies include:

• Gradual rehydration over 48 hours 2
• Avoid excessive fluid administration
• Avoid rapid changes in serum osmolality
• Careful monitoring of neurological status

Signs of Cerebral Edema:

• Headache, altered mental status, irritability
• Decreased heart rate, increased blood pressure
• Abnormal pupillary responses
• Posturing

Management of Cerebral Edema:

• Mannitol 0.5-1 g/kg IV immediately 2
• Reduce fluid administration rate
• Elevate head of bed
• Hyperventilation may be considered temporarily
• Transfer to PICU

Transition to Subcutaneous Insulin

Transition when:

• Blood glucose <200 mg/dL
• Serum bicarbonate ≥18 mEq/L
• Venous pH ≥7.3
• Patient can tolerate oral intake

Protocol:

1. Administer subcutaneous insulin 1-2 hours before stopping IV insulin
2. Initial subcutaneous regimen: 0.6-1.0 U/kg/day divided into basal and bolus doses
3. Adjust to 0.4-0.7 U/kg/day at discharge based on patient needs 5

Special Considerations

Recurrent DKA

Recurrent DKA is often associated with insulin omission and has higher morbidity and mortality 4. Psychological counseling is recommended for these patients and their families.

Prevention Strategies

• Education on early warning signs of DKA
• Sick day management protocols
• Regular blood glucose monitoring
• Ensuring uninterrupted access to insulin
• 24-hour telephone availability for patients/families 4

Alternative Approaches

In resource-limited settings where PICU beds are scarce, alternative protocols may be considered:

• Subcutaneous rapid-acting insulin analog (0.15 U/kg every 2-3 hours) until resolution of acidosis 5, 6
• Earlier transition to oral rehydration when tolerated 5

This approach has shown effectiveness in studies but should be reserved for settings where conventional management is not feasible.

Key Pitfalls to Avoid

• Administering insulin bolus (outdated practice)
• Rapid fluid administration increasing risk of cerebral edema
• Failure to monitor potassium closely
• Inadequate neurological monitoring
• Bicarbonate administration (only for severe acidosis with pH <6.9)
• Premature transition to subcutaneous insulin

The management of pediatric DKA has evolved to emphasize slower rehydration and careful monitoring to reduce the risk of cerebral edema, which remains the most serious complication.