What is the management of diabetic ketoacidosis (DKA) in children?

Management of Diabetic Ketoacidosis in Children

The management of diabetic ketoacidosis (DKA) in children requires immediate fluid resuscitation with normal saline, continuous intravenous insulin at 0.1 U/kg/hour without bolus, and careful monitoring to prevent complications, particularly cerebral edema, which is the leading cause of mortality in pediatric DKA. 1

Diagnosis and Classification

DKA is characterized by:

• Blood glucose >250 mg/dL
• Venous pH <7.3
• Bicarbonate <15 mEq/L
• Moderate ketonuria or ketonemia 2

Severity classification:

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

Initial Assessment

Upon presentation, obtain:

• Arterial blood gases
• Complete blood count with differential
• Urinalysis
• Plasma glucose
• Blood urea nitrogen (BUN)
• Electrolytes
• Chemistry profile
• Creatinine levels
• Electrocardiogram 2

Fluid Management

1. Initial Fluid Resuscitation:

   • For pediatric patients: Normal saline (0.9% NaCl) at 10-20 ml/kg/hr during the first hour, not exceeding 50 ml/kg over the first 4 hours 1
   • This is critical to expand intravascular volume and restore renal perfusion

2. Subsequent Fluid Management:

   • After initial resuscitation, fluid choice depends on corrected serum sodium levels
   • Half normal saline (0.45% NaCl) is preferred when the corrected serum sodium is normal or elevated 1
   • Fluid should be calculated to rehydrate evenly over at least 48 hours 3
   • When serum glucose reaches 250 mg/dl, change fluid to 5% dextrose with 0.45-0.75% NaCl 1

Insulin Therapy

1. Initiation:

   • Do NOT administer an initial insulin bolus in pediatric patients 2
   • Start continuous intravenous insulin infusion at 0.1 U/kg/hour 2, 1, 3
   • Delay insulin administration by 1-2 hours after starting fluid therapy 4

2. Monitoring and Adjustment:

   • If plasma glucose does not fall by 50 mg/dl in the first hour, check hydration status
   • If hydration is acceptable, the insulin infusion may be doubled every hour until a steady glucose decline between 50-75 mg/h is achieved 2
   • Continue insulin infusion until DKA resolves (glucose <200 mg/dl, serum bicarbonate ≥18 mEq/L, venous pH >7.3) 1

3. Transition to Subcutaneous Insulin:

   • Begin subcutaneous insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia 1
   • For mild DKA, subcutaneous regular insulin may be given every 4 hours 2

Electrolyte Management

1. Potassium:

   • Hold insulin until serum potassium >3.3 mEq/L 1
   • For serum potassium 3.3-5.3 mEq/L, add 20-30 mEq potassium to each liter of IV fluid 1
   • Hold potassium replacement if serum potassium >5.3 mEq/L 1
   • Potassium replacement should begin early and be sufficient 4

2. Bicarbonate:

   • Bicarbonate administration is contraindicated in pediatric DKA 4

Monitoring

1. Frequent Monitoring:

   • Vital signs, neurologic status, and biochemistry should be monitored frequently 4
   • Blood should be drawn every 2-4 hours for electrolytes, glucose, BUN, creatinine, osmolality, and venous pH 2
   • Capillary blood glucose should be measured hourly 5

2. Neurological Monitoring:

   • Closely monitor for signs of cerebral edema, which occurs in 0.5-0.9% of all DKA episodes 5
   • Warning signs include headache, decreased mental status, irritability, abnormal pupillary responses, and rising blood pressure with decreasing heart rate

Management of Complications

Cerebral Edema

• Most common cause of death in pediatric DKA 3
• Risk factors include severity of acidosis, greater hypocapnia, higher BUN at presentation, and treatment with bicarbonate 3
• Treatment: Immediate administration of mannitol (0.5-1 g/kg) or hypertonic saline 1, 4
• Reduce fluid administration rate and elevate the head of the bed
• Consider intubation for severe cases

Hypoglycemia

• Monitor closely when glucose levels approach 250 mg/dL
• Add dextrose to IV fluids when glucose reaches 250 mg/dL 1

Hypokalemia

• Can lead to cardiac arrhythmias
• Monitor potassium levels closely and replace as needed 1

Resolution Criteria for DKA

DKA is considered resolved when:

• Glucose <200 mg/dL
• Serum bicarbonate ≥18 mEq/L
• Venous pH >7.3 1

Prevention of Recurrent DKA

• Recurrent DKA is almost always due to insulin omission 2
• Children with recurrent DKA have higher incidence of psychiatric illness, especially depression 2
• Prevention strategies include:
  • Education about ketone monitoring
  • 24-hour telephone availability for healthcare team
  • Encouragement to contact healthcare team when blood glucose levels are high or ketones are present
  • Psychological counseling for children with recurrent DKA and their families 2

Special Considerations

• For patients with new-onset diabetes and DKA, manage according to type 1 diabetes protocols initially 2
• After resolution of ketoacidosis in patients with suspected type 2 diabetes, metformin can be initiated while continuing subcutaneous insulin 2

By following this comprehensive approach to managing pediatric DKA, focusing on careful fluid resuscitation, appropriate insulin therapy, and vigilant monitoring for complications, the risk of adverse outcomes, particularly cerebral edema, can be minimized.