BSPED Guidelines for Pediatric DKA Management in a 30-kg Child
Begin immediate fluid resuscitation with 0.9% normal saline at 10-20 mL/kg (300-600 mL for a 30-kg child) over the first hour, followed 1-2 hours later by continuous IV regular insulin at 0.05-0.1 units/kg/hour (1.5-3 units/hour), while never exceeding 50 mL/kg total fluid in the first 4 hours to prevent cerebral edema. 1, 2, 3
Initial Assessment and Diagnosis
Obtain STAT laboratory studies including venous blood gas, complete blood count with differential, urinalysis, plasma glucose, BUN, electrolytes, creatinine, calcium, and phosphorus. 1 Measure β-hydroxybutyrate directly rather than using nitroprusside testing, which only detects acetoacetate and acetone. 1
Calculate corrected serum sodium by adding 1.6 mEq/L for each 100 mg/dL increase in glucose above 100 mg/dL. 1, 2 Estimate effective serum osmolality as 2 × [Na (mEq/L)] + [glucose (mg/dL)] ÷ 18. 1
Fluid Management Protocol
Phase 1: Initial Resuscitation (Hour 0-1)
Administer 0.9% normal saline at 10-20 mL/kg (300-600 mL for a 30-kg child) over the first hour. 1, 2, 3 This is the critical threshold: never exceed 50 mL/kg total fluid volume in the first 4 hours, as this is the most important factor in preventing cerebral edema in children. 1, 2
Phase 2: Ongoing Fluid Therapy (Hours 1-24)
If corrected sodium is normal or elevated, switch to 0.45% NaCl at 4-14 mL/kg/hour (120-420 mL/hour for a 30-kg child). 1, 2 If corrected sodium is low, continue 0.9% NaCl at the same rate. 1, 2
An alternative smooth-rehydration strategy is to provide 1.5 × maintenance fluids (approximately 5 mL/kg/hour for a 30-kg child). 1
Critical osmolality rule: Serum osmolality must change ≤3 mOsm/kg per hour to prevent cerebral edema. 1, 2 Recheck electrolytes, glucose, BUN, creatinine, and osmolality every 2-4 hours. 1, 3
Insulin Therapy
Do NOT give an initial IV insulin bolus in pediatric patients—this is a critical difference from adult DKA protocols. 1, 2, 3
Initiate continuous IV regular insulin infusion 1-2 hours after starting fluid resuscitation at 0.05-0.1 units/kg/hour (1.5-3 units/hour for a 30-kg child). 1, 3 This delay allows for initial volume restoration before insulin drives glucose and potassium intracellularly. 4
If plasma glucose fails to drop ≥50 mg/dL in the first hour, confirm adequate hydration and then double the insulin rate hourly until a steady decline is achieved. 1
Continue insulin until ketoacidosis resolves (pH >7.3, bicarbonate ≥15-18 mEq/L, anion gap normalized), not merely until glucose normalizes. 1, 3 This is essential because ketoacidosis resolution lags behind glucose normalization.
Potassium Management
Never add potassium until urine output is confirmed at ≥0.5 mL/kg/hour (≥15 mL/hour for a 30-kg child). 1 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. 2, 3
Once adequate urine output is confirmed, add 20-30 mEq/L potassium to IV fluids, using a mixture of 2/3 potassium chloride and 1/3 potassium phosphate. 1, 2, 3 This combination replaces both chloride and phosphate losses while maintaining serum potassium at 4-5 mEq/L.
Transition to Dextrose-Containing Fluids
When plasma glucose falls to approximately 250 mg/dL, switch to 5% dextrose in 0.45% NaCl (or 0.45-0.75% NaCl based on sodium status) while maintaining potassium supplementation (20-30 mEq/L, 2/3 KCl + 1/3 KPO₄). 1
Continue the insulin infusion at 0.1 units/kg/hour (3 units/hour for a 30-kg child), adjusting dextrose concentration to keep glucose 150-200 mg/dL. 1 This "two-bag system" allows independent adjustment of glucose and electrolyte delivery while maintaining consistent insulin infusion.
Monitoring Protocol
Hourly monitoring: blood glucose and neurological status (mental status, headache, behavior changes). 1, 3
Every 2-4 hours: serum electrolytes (Na, K, Cl), venous pH and bicarbonate, BUN, creatinine, and osmolality. 1, 2, 3
Continuous cardiac monitoring is essential given the risk of arrhythmias from potassium shifts. 1
Severe DKA (pH <7.0, Bicarbonate <10 mEq/L)
Requires ICU admission with central venous and intra-arterial pressure monitoring. 1 More frequent blood chemistry determinations are necessary to guide therapy. 1 Children with severe DKA have a higher risk of cerebral edema and mortality. 1
Cerebral Edema Recognition and Management
Cerebral edema is the most common life-threatening complication of pediatric DKA and occurs more frequently in children than adults. 1, 5 Early warning signs include headache, confusion, behavioral changes, and declining mental status. 1, 3
If cerebral edema is suspected, immediately administer IV mannitol 0.5-1 g/kg over 15 minutes. 3 Hypertonic saline (3%) at 2.5-5 mL/kg over 10-15 minutes is an alternative. 6
Common pitfall: The most critical error is exceeding 50 mL/kg total fluid in the first 4 hours, which dramatically increases cerebral edema risk. 1, 2
Resolution Criteria and Transition
DKA is considered resolved when: glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L. 2, 3
Administer basal subcutaneous insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia and recurrent ketoacidosis. 3 Continue IV insulin for 1-2 hours after starting subcutaneous insulin. 1
Prevention of Recurrent DKA
Provide 24-hour telephone support for families of children with type 1 diabetes. 1 Educate caregivers on early signs of DKA and the importance of ketone monitoring during intercurrent illness. 1, 7
Emphasize that recurrent DKA is almost always due to insulin omission. 1, 4 Offer psychological support, as recurrent DKA is associated with higher rates of psychiatric illness, depression, and eating disorders. 1
Important distinction: Recent evidence suggests that early isotonic fluid therapy does not confer additional risk and may improve outcomes, leading BSPED to adopt a more permissive approach to fluid administration in their 2020 update. 5, 6 However, the critical threshold of not exceeding 50 mL/kg in the first 4 hours remains paramount. 1, 2