How to manage a pediatric patient with diabetic ketoacidosis (DKA)?

Management of Pediatric Diabetic Ketoacidosis

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 after initial fluid resuscitation, while never exceeding 50 mL/kg total fluid volume in the first 4 hours to prevent cerebral edema. 1, 2

Initial Assessment and Stabilization

Diagnostic Confirmation

• Confirm DKA diagnosis with blood glucose >250 mg/dL, venous pH <7.3, serum bicarbonate <15 mEq/L, and moderate ketonuria or ketonemia 3
• Classify severity: mild (pH 7.25-7.30), moderate (pH 7.00-7.24), or severe (pH <7.00) to guide intensity of monitoring 3

Immediate Laboratory Workup

• Obtain blood glucose, venous blood gases, complete metabolic panel with electrolytes, serum β-hydroxybutyrate (preferred over urine ketones), complete blood count with differential, urinalysis, and electrocardiogram 1, 3
• Calculate corrected sodium by adding 1.6 mEq/L for each 100 mg/dL glucose above 100 mg/dL—this is essential for accurate fluid selection 2, 3

Fluid Management Protocol

First Hour (Critical Window)

• Administer 0.9% normal saline at 10-20 mL/kg over 60 minutes to restore intravascular volume and renal perfusion 1, 2
• Never exceed 50 mL/kg total fluid volume in the first 4 hours—this is the single most critical threshold for preventing cerebral edema in children 1, 2
• Do not use hypotonic fluids initially, as this accelerates dangerous osmotic shifts 2

Subsequent Fluid Management (After First Hour)

• If corrected sodium is normal or elevated: switch to 0.45% NaCl at 4-14 mL/kg/hour 2
• If corrected sodium is low: continue 0.9% NaCl at reduced rates of 4-14 mL/kg/hour 2
• Target total fluid replacement to correct estimated deficits over 24-48 hours using 1.5 times the 24-hour maintenance requirements 1
• Monitor that induced change in serum osmolality never exceeds 3 mOsm/kg/hour 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, 3
• Start continuous IV regular insulin infusion at 0.05-0.1 units/kg/hour only after initial fluid resuscitation has begun (delay insulin by 1-2 hours after starting fluids) 1, 3
• Target glucose reduction of 50-100 mg/dL per hour and adjust insulin infusion rate accordingly 1, 2
• Continue insulin infusion until DKA resolves (pH >7.3, bicarbonate ≥18 mEq/L, anion gap ≤12 mEq/L) 1, 3

Potassium Replacement

Critical Safety Rule

• Never start insulin if serum potassium is <3.3 mEq/L—aggressively replace potassium first, as insulin will drive potassium intracellularly and precipitate life-threatening arrhythmias 1, 2

Replacement Protocol

• Once adequate urine output is confirmed and potassium <5.5 mEq/L, add 20-30 mEq/L potassium to IV fluids 1, 2, 3
• Use a mixture of 2/3 KCl and 1/3 KPO4 to provide both chloride and phosphate 1, 2, 3
• Target serum potassium maintenance at 4-5 mEq/L 3

Monitoring Protocol

Frequency and Parameters

• Monitor blood glucose hourly or more frequently 2, 3
• Check serum electrolytes, BUN, creatinine, osmolality, and venous pH every 2-4 hours 1, 2, 3
• Perform neurological checks hourly to detect early signs of cerebral edema 3
• Monitor vital signs continuously 2

Cerebral Edema Recognition

• Watch for deteriorating mental status, severe headache, bradycardia with hypertension, or altered level of consciousness 1
• If cerebral edema is suspected, immediately administer IV mannitol 0.5-1 g/kg over 15 minutes 1
• This is the most feared complication with high morbidity and mortality—early recognition is critical 4

Resolution and Transition

DKA Resolution Criteria

• Consider DKA resolved when glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L 1, 2
• Continue monitoring β-hydroxybutyrate until normalized 1

Transition to Subcutaneous Insulin

• Administer basal subcutaneous insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia and recurrent ketoacidosis 1, 3
• Continue IV insulin for 1-2 hours after starting subcutaneous insulin 3

Critical Pitfalls to Avoid

• Excessive fluid administration in the first 4 hours remains the most common error in pediatric DKA management 5
• Never give IV insulin bolus in children (unlike adult protocols) 1, 2, 3
• Never start insulin before correcting severe hypokalemia (<3.3 mEq/L) 1, 2
• Never use hypotonic fluids during initial resuscitation 2
• Never allow osmolality changes to exceed 3 mOsm/kg/hour 2