What is the recommended initial insulin drip rate for pediatric diabetic ketoacidosis (DKA)?

Recommended Insulin Drip Rate for Pediatric DKA

The recommended initial insulin drip rate for pediatric diabetic ketoacidosis (DKA) is 0.05-0.10 units/kg/hour as a continuous intravenous infusion, with no initial bolus dose. 1, 2

Initial Insulin Administration

• An initial insulin bolus is NOT recommended in pediatric patients with DKA 1, 2
• Start with a continuous insulin infusion of regular insulin at 0.1 unit/kg/hour 1, 2
• Recent evidence suggests that a lower dose of 0.05 unit/kg/hour may be equally effective and potentially safer 3, 4

Monitoring and Adjustments

• If plasma glucose does not fall by at least 50 mg/dL from the initial value in the first hour:
  • Check hydration status first 1
  • If hydration is acceptable, double the insulin infusion rate every hour until achieving a steady glucose decline of 50-75 mg/dL/hour 1
• Monitor blood glucose and potassium concentrations hourly or more frequently as needed 1
• The goal is to gradually reduce blood glucose by 50-100 mg/dL per hour 1

Glucose Administration

• When plasma glucose reaches 250 mg/dL:
  • Add 5% dextrose to intravenous fluids (change to D5W with 0.45-0.75% NaCl) 1
  • Continue insulin infusion to clear ketosis 1, 2
  • Consider reducing insulin infusion rate to 0.05-0.1 units/kg/hour 1

Safety Considerations

• Lower insulin doses (0.05 units/kg/hour) are associated with:
  • Reduced risk of hypokalemia (RR 0.65; 95% CI 0.47-0.89) 4
  • Reduced risk of hypoglycemia (RR 0.37; 95% CI 0.15-0.80) 4
  • Similar efficacy in resolving acidosis and hyperglycemia 3, 4
• Standard insulin dosing regimens (0.1 units/kg/hour) frequently result in serum glucose decreases greater than 100 mg/dL/hour, which may increase risk of cerebral edema 5

Laboratory Monitoring

• Draw blood every 2-4 hours to determine:
  • Serum electrolytes
  • Glucose
  • Blood urea nitrogen
  • Creatinine
  • Venous pH 1
• Direct measurement of β-hydroxybutyrate in blood is preferred for monitoring DKA resolution 1, 2

Transition to Subcutaneous Insulin

• Once DKA is resolved (glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH ≥7.3) and the patient can eat:
  • Initiate a multidose regimen of subcutaneous insulin 1, 2
  • Combine short/rapid-acting and intermediate/long-acting insulin 1, 2

Common Pitfalls to Avoid

• Administering an initial insulin bolus in pediatric patients, which is no longer recommended 1, 6
• Decreasing serum glucose too rapidly (>100 mg/dL/hour), which increases risk of cerebral edema 5
• Relying solely on urine ketones to monitor resolution of ketosis 1
• Discontinuing insulin infusion too early before acidosis is resolved 1, 2