Management of Diabetic Ketoacidosis in a 10-Year-Old Child
Immediately initiate intravenous insulin therapy at 0.1 units/kg/hour without an initial bolus, preceded by 1-2 hours of fluid resuscitation with isotonic saline, and continue until acidosis resolves (pH >7.3, bicarbonate >15 mEq/L). 1, 2
Initial Assessment and Diagnosis
Obtain STAT laboratory studies including arterial blood gases, complete blood count with differential, urinalysis, plasma glucose, BUN, electrolytes, chemistry profile, creatinine, and electrocardiogram 1, 2. Calculate corrected sodium by adding 1.6 mEq to the measured sodium value for each 100 mg/dL of glucose above 100 mg/dL 1, 2. Measure β-hydroxybutyrate directly in blood rather than using the nitroprusside method, as nitroprusside only detects acetoacetic acid and acetone, not the predominant ketone β-hydroxybutyrate 1, 2.
Confirm DKA diagnosis with blood glucose >250 mg/dL, venous pH <7.3, serum bicarbonate <15 mEq/L, and moderate ketonuria or ketonemia 1. Classify severity as mild (pH 7.25-7.30, bicarbonate 15-18 mEq/L), moderate (pH 7.00-7.24, bicarbonate 10-15 mEq/L), or severe (pH <7.00, bicarbonate <10 mEq/L) 1.
Fluid Management Protocol
Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg over the first hour to restore circulatory volume 1. After initial resuscitation, transition to 0.45% saline at 1.5 times maintenance requirements (approximately 5 mL/kg/hour) to replace the estimated 5-10% dehydration 1, 3. Avoid excessive fluid administration beyond these recommendations, as historical concerns about cerebral edema have led to conservative fluid protocols, though recent evidence questions this causation 4.
A critical pitfall: Studies show that 82% of patients at primary/secondary centers and 67% at tertiary centers receive excessive fluids (>10 mL/kg in the first hour), which deviates from current recommendations 5. Do not exceed two times the maintenance requirement 2.
Insulin Therapy
Do not administer an initial insulin bolus in pediatric patients 1, 2. This represents a key difference from adult protocols and is a strong recommendation from the American Diabetes Association 2. Start continuous IV regular insulin infusion at 0.1 units/kg/hour only after fluid resuscitation has begun, delaying insulin by 1-2 hours after starting fluids 1, 3.
Monitor plasma glucose every 1-2 hours until stable 1. Expect glucose to decrease at 50-75 mg/dL per hour 2. If glucose does not fall by 50 mg/dL in the first hour, verify adequate hydration status, then double the insulin infusion rate hourly until achieving steady glucose decline of 50-75 mg/dL per hour 2.
When plasma glucose reaches 250 mg/dL, add dextrose to IV fluids while continuing insulin infusion at 0.1 units/kg/hour 2. Continue insulin until ketoacidosis resolves completely: pH >7.3, bicarbonate >15 mEq/L, and anion gap normalized 1.
Electrolyte Management
Begin potassium replacement when serum levels fall below 5.5 mEq/L and adequate urine output is confirmed 1. Add 20-30 mEq potassium per liter of infusion fluid, using 2/3 KCl and 1/3 KPO₄ to maintain serum potassium between 4-5 mEq/L 1, 2. Do not start insulin if potassium is <3.3 mEq/L 2.
Monitor serum electrolytes, glucose, BUN, creatinine, osmolality, and venous pH every 2-4 hours 1, 2. Repeat arterial blood gases are generally unnecessary; venous pH and anion gap adequately monitor acidosis resolution 2.
Monitoring for Complications
Perform neurological checks hourly to detect early signs of cerebral edema 1. Cerebral edema is rare but represents the most severe complication, occurring predominantly in children 6. Signs include altered mental status, severe headache, vomiting, bradycardia, and hypertension 3. If cerebral edema develops, immediately administer mannitol or hypertensive saline 3.
Transition to Subcutaneous Insulin
Start subcutaneous insulin 2-4 hours before discontinuing IV insulin 1. Continue IV insulin for 1-2 hours after administering subcutaneous insulin to prevent recurrence of ketoacidosis 1. This overlap is essential to maintain adequate insulin levels during the transition.
Once acidosis resolves, initiate metformin while continuing subcutaneous insulin therapy 2. Determine diabetes type through pancreatic autoantibody testing 2. If autoantibodies are negative (suggesting type 2 diabetes), continue or start metformin and titrate insulin based on blood glucose monitoring 2. If autoantibodies are positive (confirming type 1 diabetes), continue multiple daily injection insulin or pump therapy and discontinue metformin 2.
Prevention of Recurrent DKA
Recurrent DKA is almost always due to insulin omission and requires comprehensive education and psychosocial support 3, 1. Provide education about DKA signs and symptoms, ensure 24-hour telephone availability for families, teach ketone monitoring during illness, and arrange psychological support for patients with recurrent episodes 1.