Management of Diabetic Ketoacidosis in Children
Initiate continuous IV regular insulin at 0.05–0.1 U/kg/hour WITHOUT an initial bolus, starting 1–2 hours after fluid resuscitation begins, and continue until ketoacidosis fully resolves—not just until glucose normalizes. 1
Initial Assessment & Diagnostic Workup
Obtain STAT laboratory studies including venous blood gas, complete blood count with differential, urinalysis, plasma glucose, BUN, electrolytes, creatinine, calcium, and phosphorus in all children with suspected DKA. 1
Key diagnostic criteria:
- Blood glucose >250 mg/dL 2
- Venous pH <7.3 2
- Serum bicarbonate <15 mEq/L 2
- Moderate ketonuria or ketonemia 2
Measure β-hydroxybutyrate directly rather than relying on nitroprusside-based urine ketone tests, which only detect acetoacetate and acetone while missing the predominant ketone body. 1
Calculate corrected serum sodium by adding 1.6 mEq/L for each 100 mg/dL increase in glucose above 100 mg/dL to guide fluid selection. 1
Severity classification guides monitoring intensity:
- Severe DKA (pH <7.0, bicarbonate <10 mEq/L): requires ICU admission with central venous and intra-arterial pressure monitoring due to higher risk of cerebral edema and mortality 1
- Moderate DKA (pH 7.0–7.24, bicarbonate 10–15 mEq/L) 2
- Mild DKA (pH 7.25–7.30, bicarbonate 15–18 mEq/L) 2
Fluid Management Protocol
Phase 1: Initial Resuscitation (Hour 0–1)
Begin with 0.9% normal saline at 10–20 mL/kg over the first hour (300–600 mL for a 30-kg child), but do not exceed 50 mL/kg total in the first 4 hours to minimize cerebral edema risk. 1
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
If corrected sodium is low, continue 0.9% NaCl at the same rate. 1
An alternative smooth-rehydration strategy is to provide 1.5 × maintenance fluids (approximately 5 mL/kg/hour for a 30-kg child). 1
Critical monitoring parameter: Serum osmolality should change ≤3 mOsm/kg per hour; check electrolytes, glucose, BUN, creatinine, and osmolality every 2–4 hours. 1
Insulin Therapy
DO NOT give an initial IV insulin bolus in pediatric patients—this is a critical difference from adult protocols and prevents rapid glucose drops that increase cerebral edema risk. 1
Initiate continuous IV regular insulin infusion 1–2 hours after fluid resuscitation at 0.05–0.1 U/kg/hour (approximately 1.5–3 U/hour for a 30-kg child). 1
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, as ketone clearance takes longer than glucose correction. 1
Potassium Management
Add potassium ONLY after urine output is ≥0.5 mL/kg/hour (≥15 mL/hour for a 30-kg child) to confirm adequate renal function. 1
Once 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
Critical pitfall: Total body potassium is depleted by 3–5 mEq/kg in DKA despite normal or elevated initial serum levels, and insulin therapy drives potassium intracellularly, causing rapid decline. 1
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 U/kg/hour, adjusting dextrose concentration to keep glucose 150–200 mg/dL. 1
Rationale: Both insulin and glucose are required to clear ketones; insulin alone cannot resolve ketonemia without adequate carbohydrate substrate. 1
Monitoring Throughout Treatment
Hourly: Blood glucose and neurological status (mental status, headache, behavioral changes). 1
Every 2–4 hours: Serum electrolytes (Na, K, Cl), venous pH and bicarbonate, BUN, creatinine. 1
Venous pH is sufficient for monitoring—it is typically 0.03 units lower than arterial pH, eliminating the need for repeated arterial blood gases. 1
Cerebral Edema Recognition
Cerebral edema is the most common life-threatening complication of pediatric DKA and occurs more frequently in children than adults. 1
Early warning signs include:
- Headache
- Confusion
- Behavioral changes
- Declining mental status 1
Prevention strategies:
- Avoid overly aggressive fluid resuscitation (do not exceed 50 mL/kg in first 4 hours) 1
- Do not give initial insulin bolus 1
- Maintain hourly neurological assessments 1
Transition to Subcutaneous Insulin
Once ketoacidosis resolves (pH >7.3, bicarbonate ≥15–18 mEq/L), initiate subcutaneous insulin while continuing IV insulin for 1–2 hours to prevent rebound hyperglycemia. 2
For type 2 diabetes with ketoacidosis: Once acidosis resolves, metformin should be initiated while subcutaneous insulin therapy is continued. 2
For type 1 diabetes or positive pancreatic autoantibodies: Continue or initiate multiple daily injection insulin or pump therapy as for type 1 diabetes; discontinue metformin. 2
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
Emphasize that recurrent DKA is almost always due to insulin omission. 1
Offer psychological support, as recurrent DKA is associated with higher rates of psychiatric illness, depression, and eating disorders. 1