What is the reconstitution of insulin in pediatric diabetic ketoacidosis (DKA)?

Insulin Reconstitution in Pediatric DKA

For pediatric diabetic ketoacidosis (DKA), regular insulin should be administered as an intravenous (IV) infusion at 0.1 units/kg/hour without an initial bolus dose. 1

Insulin Preparation and Administration

• Regular insulin is the preferred formulation for IV administration in pediatric DKA
• Reconstitution involves:
  • Adding regular insulin to normal saline (0.9% NaCl) solution
  • Standard concentration: Calculate total units needed (0.1 units/kg/hour × expected hours of treatment)
  • No initial bolus dose is needed according to American Diabetes Association guidelines 1

Administration Route Considerations

• IV route is the standard of care for insulin administration in pediatric DKA
• Alternative routes when IV access cannot be established:
  • Intraosseous (IO) route can be effectively used for insulin infusion at the same rate (0.1 units/kg/hour) when IV access is unobtainable 2
  • Subcutaneous insulin may be considered in specific circumstances:
    • For mild to moderate DKA: Subcutaneous rapid-acting insulin (aspart) at 0.15 units/kg every 2 hours 3
    • Some centers have used subcutaneous regular insulin at 0.15 units/kg every 4 hours for DKA with pH ≥ 7.0 4

Monitoring and Titration

• Monitor blood glucose hourly until stable
• Target glucose level: 150-200 mg/dL for DKA patients 1
• When blood glucose reaches 200-250 mg/dL:
  • Add dextrose to IV fluids (D5 or D10)
  • Continue insulin infusion until metabolic acidosis resolves (pH >7.3, bicarbonate ≥18 mEq/L) 1

Transition to Subcutaneous Insulin

• Administer subcutaneous basal insulin 2-4 hours before discontinuing IV insulin infusion to prevent rebound hyperglycemia 1
• For established type 1 diabetes: Resume previous insulin regimen if adequate
• For newly diagnosed diabetes: Start with total daily dose of 0.6-1.0 units/kg/day 5

Common Pitfalls to Avoid

• Abrupt discontinuation of IV insulin without proper transition to subcutaneous insulin can lead to rebound hyperglycemia and recurrence of DKA 1
• Excessive insulin dosing increases risk of hypoglycemia and requires frequent glucose monitoring
• Initial bolus doses of insulin are not recommended and may accelerate glucose decline too rapidly 6
• Inadequate fluid resuscitation alongside insulin therapy can worsen outcomes

Special Considerations

• In resource-limited settings without pediatric ICU beds, alternative protocols using subcutaneous insulin may be considered for mild-moderate DKA 5, 3
• For severe dehydration when IV access cannot be obtained, intraosseous access should be considered for both fluid resuscitation and insulin administration 2