What are the treatment guidelines for pediatric patients with diabetic ketoacidosis (DKA)?

Pediatric DKA Treatment Guidelines

Begin immediate fluid resuscitation with 0.9% normal saline at 10-20 mL/kg over the first hour, never exceeding 50 mL/kg total in the first 4 hours, followed by continuous insulin infusion at 0.05-0.1 units/kg/hour (without an initial bolus) only after hemodynamic stability is achieved. 1

Initial Resuscitation Phase

Fluid Bolus

• Administer 0.9% normal saline at 10-20 mL/kg over the first hour to restore intravascular volume and renal perfusion 1, 2
• Critical threshold: Never exceed 50 mL/kg total fluid volume in the first 4 hours—this is the most important safeguard against cerebral edema in children 1, 3
• Avoid hypotonic fluids initially as they accelerate dangerous osmotic shifts and increase cerebral edema risk 1

Insulin Timing

• Do NOT administer insulin during initial fluid resuscitation—wait 1-2 hours until hemodynamic stability is achieved 1, 2
• Do NOT give IV bolus insulin in pediatric patients—this differs critically from adult protocols and increases complication risk 1, 4
• Start continuous insulin infusion at 0.05-0.1 units/kg/hour only after initial fluid resuscitation 1, 2

Subsequent Fluid Management (After First Hour)

Fluid Selection Based on Corrected Sodium

• If corrected sodium is normal or elevated: Switch to 0.45% NaCl (half-normal saline) at 4-14 mL/kg/hour 1, 3
• If corrected sodium is low: Continue 0.9% NaCl at reduced rates of 4-14 mL/kg/hour 1, 3
• Calculate corrected sodium by adding 1.6 mEq/L for each 100 mg/dL glucose above 100 mg/dL 1, 3

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, 3

Potassium Replacement Protocol

• Add 20-30 mEq/L potassium to IV fluids once adequate urine output is confirmed 1, 2
• Use a mixture of 2/3 KCl and 1/3 KPO4 1, 3
• Never add potassium if serum K+ is <3.3 mEq/L until it is corrected—insulin will drive potassium intracellularly and precipitate life-threatening arrhythmias 1, 3
• Potassium replacement must begin early and be sufficient to prevent hypokalemia 2

Insulin Infusion Management

Starting Insulin

• Begin continuous insulin infusion at 0.05-0.1 units/kg/hour only after initial fluid resuscitation 1, 2
• Target glucose reduction of 50-100 mg/dL per hour 1
• If glucose does not decrease by at least 50 mg/dL in the first hour, verify hydration status and double the insulin infusion rate hourly until achieving steady decline 4

Glucose Management

• When plasma glucose reaches 200-250 mg/dL, add dextrose (D5W or D10W) to IV fluids while continuing insulin infusion to prevent hypoglycemia and continue correcting ketosis 1, 3, 4
• Continue insulin infusion at 0.1 units/kg/hour until ketoacidosis fully resolves 3

Monitoring Parameters

Continuous Monitoring

• Vital signs and neurological status continuously 1
• Blood glucose hourly or more frequently 1, 3
• Serum electrolytes, BUN, creatinine, osmolality, and venous pH every 2-4 hours 1, 3, 4

Preferred Ketone Monitoring

• Measure β-hydroxybutyrate directly rather than using nitroprusside method, which only detects acetoacetic acid and acetone, not the predominant ketone 3, 4

Resolution Criteria and Transition

DKA Resolution Defined As:

• Glucose <200 mg/dL 1, 4
• Serum bicarbonate ≥18 mEq/L 1, 4
• Venous pH >7.3 1, 4
• Anion gap ≤12 mEq/L 1, 4

Transition to Subcutaneous Insulin

• Administer basal subcutaneous insulin 2-4 hours before stopping IV insulin infusion to prevent rebound hyperglycemia and ketoacidosis recurrence 4
• Initiate multidose subcutaneous insulin regimen combining short/rapid-acting and intermediate/long-acting insulin once patient can eat 4
• Starting dose approximately 0.5-1.0 units/kg/day for newly diagnosed patients 4

Critical Pitfalls to Avoid

• Never exceed 50 mL/kg in the first 4 hours—this is the single most important threshold for preventing cerebral edema 1, 3
• Never use hypotonic fluids initially 1
• Never give IV bolus insulin in pediatric patients 1, 4
• Never add potassium before confirming adequate urine output and K+ >3.3 mEq/L 1, 3
• Never allow osmolality to decrease faster than 3 mOsm/kg/hour 1, 3
• Never discontinue IV insulin before administering subcutaneous basal insulin 2-4 hours prior 4
• Bicarbonate administration is contraindicated 2

Cerebral Edema Management

• If signs of cerebral edema develop (altered mental status, headache, vomiting, bradycardia, hypertension), immediately administer mannitol or hypertensive saline 2, 5
• Cerebral edema is the most common cause of death in pediatric DKA and requires rapid intervention 2, 5
• Risk factors include overhydration, rapid osmolar shifts, and hypoxia 5