Pediatric DKA Management — 13-Year-Old (RBS 383 mg/dL)

Step 0 — Confirm Diagnosis

• Mild: pH 7.20–7.30, HCO₃ 10–15
• Moderate: pH 7.10–7.20, HCO₃ 5–10
• Severe: pH <7.10, HCO₃ <5

Step 1 — Initial Assessment & Monitoring

• Weigh the patient (all fluid/insulin doses are weight-based)
• Secure IV access; send: CBC, BMP (Na, K, Cl, CO₂), Ca, Mg, PO₄, β-hydroxybutyrate, venous blood gas, serum lactate, urinalysis, HbA1c
• Continuous cardiac monitoring (hypokalemia → arrhythmia risk)
• Urine output monitoring (catheterize if comatose)
• Check for precipitant: infection, missed insulin doses, new-onset diabetes

Step 2 — Fluid Resuscitation

Fluids alone decrease blood glucose via dilution, glucosuria, and improved tissue perfusion.

Phase 1 — Emergency Bolus (if hemodynamically compromised)

• Normal saline (0.9% NaCl): 10–20 mL/kg IV over 1 hour
• Repeat bolus if perfusion remains inadequate
• Do NOT use hypotonic saline for initial bolus

Phase 2 — Rehydration (deficit replacement over 24–48 hours)

• Subtract initial bolus volume from total deficit
• Replace remaining deficit + maintenance fluids over 24–48 hours
• Use 0.45–0.9% NaCl with 20–40 mEq/L KCl (once urine output confirmed and K⁺ < 5 mEq/L)
• Target glucose fall: ~50–100 mg/dL/hour (not faster)
• When glucose falls to ~250–300 mg/dL → add dextrose to IV fluid (D5 or D10 in NS) to allow continued insulin infusion without hypoglycemia

Step 3 — Potassium Replacement (CRITICAL — do before insulin if K⁺ low)

Step 4 — Insulin Therapy

1. IV fluids running for at least 1 hour
2. Potassium is ≥3.5 mEq/L

Protocol:

• Regular insulin (IV infusion): 0.1 unit/kg/hour (continuous infusion — standard)
• Lower dose 0.05 unit/kg/hr may be used in mild DKA or young children
• Do NOT give IV insulin bolus (increases cerebral edema risk in children)
• Target glucose fall: 50–100 mg/dL/hour
• Continue insulin infusion until:
  • pH >7.30
  • HCO₃ >15 mEq/L
  • Patient tolerating oral intake
• Then transition to subcutaneous insulin with 1–2 hr overlap before stopping infusion

Step 5 — Bicarbonate?

• Severe acidosis: pH <6.9 with hemodynamic instability
• Life-threatening hyperkalemia

Step 6 — Phosphate

• Replace only if severe hypophosphatemia (<1 mg/dL) or symptomatic
• Use potassium phosphate as part of K replacement if needed

Step 7 — Monitoring During Treatment

⚠️ Key Complication: Cerebral Edema

• Age <5 years
• Severe acidosis
• Severe hyperosmolality
• Failure of serum Na⁺ to rise as glucose falls
• Younger age, high BUN at presentation

• Severe headache
• Declining mental status / deteriorating GCS
• Bradycardia + hypertension (Cushing response)
• Papilledema, seizures

• Mannitol 0.5–1 g/kg IV bolus (or 3% saline 5–10 mL/kg over 30 min)
• Fluid restriction
• Elevate head of bed 30°
• Intubation with controlled ventilation if airway compromised
• Do NOT wait for CT scan — treat clinically

Summary Flow for This Patient

383 mg/dL glucose + ketones + acidosis (confirm VBG) 
→ IV access, labs, weigh patient
→ 0.9% NS 10–20 mL/kg bolus (if dehydrated/shocked)
→ Check K⁺ before insulin
→ Start insulin 0.1 U/kg/hr after 1 hr of fluids
→ Add dextrose when glucose ~250–300 mg/dL
→ Replace K⁺ throughout
→ Monitor neuro status every hour
→ Transition to SC insulin when resolved