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

Management of Diabetic Ketoacidosis (DKA) in Children

Diabetic ketoacidosis in children requires immediate treatment with insulin, fluid resuscitation, and electrolyte management in an intensive care setting to prevent life-threatening complications, particularly cerebral edema. 1, 2

Diagnostic Criteria

• DKA is defined by blood glucose >250 mg/dL, venous pH <7.3, serum bicarbonate <15 mEq/L, and moderate ketonuria or ketonemia 1
• DKA severity classification 1:
  • Mild: pH 7.25-7.30, bicarbonate 15-18 mEq/L, alert mental status
  • Moderate: pH 7.00-7.24, bicarbonate 10-15 mEq/L, drowsy mental status
  • Severe: pH <7.00, bicarbonate <10 mEq/L, stupor/coma

Initial Assessment and Stabilization

• Obtain STAT labs: arterial blood gases, complete blood count with differential, urinalysis, plasma glucose, BUN, electrolytes, chemistry profile, and creatinine 3
• Obtain chest X-ray and cultures if infection is suspected 1
• Calculate corrected sodium (add 1.6 mEq to sodium value for each 100 mg/dL glucose >100 mg/dL) 3
• Direct measurement of β-hydroxybutyrate in blood is preferred over nitroprusside method for monitoring ketones 3, 1

Fluid Management

• Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour for the first hour to restore circulatory volume 2, 4
• For less severe dehydration, use 1.5 times maintenance requirements (approximately 5 mL/kg/hr) 3
• After initial resuscitation, calculate fluid deficit assuming conservative dehydration of 6.5-8.5% 4
• Plan rehydration evenly over 48 hours to avoid rapid shifts in osmolality 5, 6
• Use 0.45% saline after initial resuscitation to replace deficit 3, 5
• Monitor closely for signs of cerebral edema, which is the most common cause of death in pediatric DKA 3, 5

Insulin Therapy

• Do not administer an initial insulin bolus in pediatric patients 3, 2
• Start continuous IV regular insulin infusion at 0.1 unit/kg/hour after fluid resuscitation has begun (delay insulin by 1-2 hours after starting fluids) 3, 7
• Continue insulin until ketoacidosis resolves (pH >7.3, bicarbonate >15 mEq/L, and anion gap normalized) 2
• When blood glucose falls below 250 mg/dL, add dextrose (5-10%) to IV fluids while continuing insulin to clear ketones 2
• For mild DKA, subcutaneous insulin may be considered, but IV administration is preferred 3

Electrolyte Management

• Potassium: Despite total body potassium depletion, serum levels may initially be normal or elevated 2
• Begin potassium replacement when serum levels fall below 5.5 mEq/L and adequate urine output is confirmed 2
• Add 20-30 mEq potassium (2/3 KCl and 1/3 KPO₄) per liter of infusion fluid to maintain serum potassium 4-5 mEq/L 3, 2
• If initial potassium is <3.3 mEq/L, start potassium replacement before insulin therapy to prevent arrhythmias 2, 8
• Bicarbonate administration is contraindicated in pediatric DKA as it may increase risk of cerebral edema 7, 5

Monitoring During Treatment

• Check blood glucose every 1-2 hours until stable 2
• Monitor serum electrolytes, glucose, BUN, creatinine, osmolality, and venous pH every 2-4 hours 3, 2
• Perform neurological checks hourly to detect early signs of cerebral edema 1, 5
• Monitor for signs of cerebral edema: headache, altered mental status, irritability, abnormal pupillary responses, bradycardia, hypertension, decreased oxygen saturation 5
• Follow venous pH and anion gap to monitor resolution of acidosis 3

Transition to Subcutaneous Insulin

• DKA resolution criteria: glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L 2
• Start subcutaneous insulin 2-4 hours before discontinuing IV insulin 2
• Continue IV insulin for 1-2 hours after starting subcutaneous insulin to prevent recurrence of ketoacidosis 2

Complications and Prevention

• Cerebral edema: Risk factors include severity of acidosis, greater hypocapnia, higher BUN at presentation, and treatment with bicarbonate 5
• If cerebral edema is suspected, administer mannitol 0.5-1 g/kg IV immediately 6
• Hypokalemia: Monitor potassium levels closely as insulin drives potassium into cells 8
• Recurrent DKA: Often due to insulin omission; requires comprehensive education and psychosocial support 3
• Prevention strategies include 3:
  • Education about signs and symptoms of DKA
  • 24-hour telephone availability for families
  • Ketone monitoring during illness
  • Psychological support for patients with recurrent DKA

Special Considerations

• Children with Type 2 diabetes who present with DKA require the same initial management as those with Type 1 diabetes 3
• For children with unclear distinction between Type 1 and Type 2 diabetes who present with ketosis or DKA, insulin therapy must be initiated 3
• Children with comorbidities like nephrogenic diabetes insipidus require individualized fluid management 9