Initial Management of Pediatric DKA
Begin immediate fluid resuscitation with 0.9% normal saline at 10-20 mL/kg over the first hour, followed by continuous IV insulin infusion at 0.05-0.1 units/kg/hour (without an initial bolus), while closely monitoring for cerebral edema—the leading cause of death in pediatric DKA. 1, 2
Immediate Assessment and Stabilization
Initial Laboratory Workup
Obtain the following STAT upon presentation 2:
- Blood glucose, venous blood gases (arterial not necessary)
- Complete metabolic panel with electrolytes, BUN, creatinine
- Serum β-hydroxybutyrate (preferred over urine ketones)
- Complete blood count with differential
- Urinalysis
- Electrocardiogram
- Cultures (blood, urine, throat) if infection suspected 3
Diagnostic Criteria Confirmation
DKA is diagnosed when all of the following are present 3, 2:
- Blood glucose >250 mg/dL
- Venous pH <7.3
- Serum bicarbonate <15 mEq/L
- Moderate ketonuria or ketonemia
Fluid Management Protocol
Phase 1: Initial Resuscitation (First Hour)
Administer 0.9% normal saline at 10-20 mL/kg over the first hour 1, 2. This restores intravascular volume and renal perfusion without causing dangerous osmotic shifts 1.
Critical safety threshold: Never exceed 50 mL/kg total fluid volume in the first 4 hours—this is the most important threshold for preventing cerebral edema in children 1.
Phase 2: Subsequent Fluid Management (After First Hour)
Calculate corrected sodium: Add 1.6 mEq/L for each 100 mg/dL glucose above 100 mg/dL 1, 2.
If corrected sodium is normal or elevated: Switch to 0.45% NaCl at 4-14 mL/kg/hour 1, 2.
If corrected sodium is low: Continue 0.9% NaCl at reduced rates of 4-14 mL/kg/hour 1, 2.
Target fluid replacement to correct estimated deficits over 24-48 hours, typically using 1.5 times the 24-hour maintenance requirements (approximately 5 mL/kg/hour) 2.
Critical Osmolality Monitoring
The induced change in serum osmolality must never exceed 3 mOsm/kg/hour to prevent cerebral edema 1, 3. Monitor serum electrolytes, glucose, and osmolality every 2-4 hours 1, 2.
Insulin Therapy
Timing and Dosing
Do NOT give an IV bolus of insulin in pediatric patients—this differs critically from adult protocols 1, 2.
Start continuous IV regular insulin infusion at 0.05-0.1 units/kg/hour only after initial fluid resuscitation 1, 2. Some guidelines suggest waiting 1-2 hours after starting fluids before initiating insulin 4.
Monitoring Insulin Response
Target glucose reduction of 50-100 mg/dL per hour 1, 2. If plasma glucose does not fall by 50 mg/dL from the initial value in the first hour, verify adequate hydration, then double the insulin infusion rate every hour until achieving steady glucose decline of 50-75 mg/dL per hour 2.
Dextrose Addition
When blood glucose falls to 250 mg/dL, add 5-10% dextrose to IV fluids while continuing insulin infusion 3, 2. This prevents hypoglycemia while allowing insulin to clear ketones, as insulin alone cannot resolve ketosis without adequate carbohydrate substrate 3.
Potassium Replacement
Critical Safety Check
Never start insulin if serum potassium is <3.3 mEq/L 2, 1. Insulin drives potassium intracellularly and can precipitate life-threatening arrhythmias 1. Aggressively replace potassium first before initiating insulin 3.
Replacement Protocol
Once adequate urine output is confirmed and potassium is known, add 20-30 mEq/L potassium to IV fluids 1, 2. Use a mixture of 2/3 KCl and 1/3 KPO4 1, 2.
Target serum potassium of 4-5 mEq/L throughout treatment 3.
Monitoring Protocol
Continuous Monitoring
- Vital signs and neurological status continuously 1
- Blood glucose hourly or more frequently 1
- Glasgow Coma Scale every 15-30 minutes if altered mental status 5
Laboratory Monitoring Every 2-4 Hours
- Serum electrolytes (sodium, potassium, chloride, bicarbonate)
- Blood glucose
- BUN and creatinine
- Serum osmolality
- Venous pH (arterial blood gases generally unnecessary after initial assessment) 2, 3
- β-hydroxybutyrate (preferred over nitroprusside-based ketone tests) 3, 2
Important caveat: The nitroprusside method only measures acetoacetic acid and acetone, completely missing β-hydroxybutyrate—the predominant ketoacid in DKA. During treatment, β-hydroxybutyrate converts to acetoacetate, which can falsely suggest worsening ketosis even as the patient improves 3, 2.
Recognition and Management of Cerebral Edema
Clinical Recognition
Cerebral edema occurs in 0.7-1.0% of pediatric DKA cases and is the leading cause of death 5. Typical onset is 4-12 hours after starting treatment 5. Watch for:
- Deteriorating mental status or declining Glasgow Coma Scale
- Severe headache
- Recurrent vomiting
- Bradycardia with hypertension
- Altered respiratory pattern
Immediate Treatment
If cerebral edema is suspected, immediately administer IV mannitol 0.5-1 g/kg over 15 minutes 5, 4. This is the treatment of choice to rapidly reduce intracranial pressure 5.
Alternative: Hypertonic saline (3%) 2.5-5 mL/kg over 10-15 minutes if mannitol unavailable 5.
Concurrent Measures
- Elevate head of bed 30 degrees 5
- Reduce IV fluid rate to 1.5 times maintenance 5
- Reduce insulin infusion rate if glucose dropping too rapidly (>90 mg/dL/hour) 5
- Do NOT increase insulin infusion or give additional fluid boluses 5
- Consider intubation if GCS continues to decline, but avoid hyperventilation unless signs of herniation 5
- Neurosurgical consultation if signs of herniation develop 5
Resolution Criteria
DKA is considered resolved when ALL of the following are met 3, 2:
- Glucose <200 mg/dL
- Serum bicarbonate ≥18 mEq/L
- Venous pH >7.3
- Anion gap ≤12 mEq/L
Ketonemia typically takes longer to clear than hyperglycemia 2, 3. Continue monitoring β-hydroxybutyrate until normalized, even after glucose normalizes.
Transition to Subcutaneous Insulin
Administer basal subcutaneous insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia and recurrent ketoacidosis 3, 2. Premature discontinuation of IV insulin when glucose normalizes is a common pitfall, as ketoacidosis takes longer to resolve than hyperglycemia 3.
Critical Pitfalls to Avoid
- Never use hypotonic fluids initially—this accelerates osmotic shifts and increases cerebral edema risk 1
- Never exceed 50 mL/kg total fluid in first 4 hours—most critical threshold for preventing cerebral edema 1
- Never give IV insulin bolus in pediatric patients 1, 2
- Never start insulin if potassium <3.3 mEq/L 2, 1
- Never rely on urine ketones or nitroprusside methods for monitoring—use direct β-hydroxybutyrate measurement 3, 2
- Never stop IV insulin when glucose normalizes—continue until ketoacidosis resolves 3
- Never use bicarbonate therapy unless pH <6.9—provides no benefit and may worsen outcomes 3, 2