Clinical Scenario:
A 12-year-old girl with known type 1 diabetes mellitus is admitted with severe diabetic ketoacidosis. On admission, she is drowsy but arousable. Her weight is 38 kg.
Initial investigations:
- Blood glucose: 31 mmol/L (558 mg/dL)
- Venous pH: 6.98
- Serum bicarbonate: 5 mmol/L
- Serum sodium: 128 mmol/L
- Serum potassium: 5.4 mmol/L
- Blood urea nitrogen: 10 mmol/L
- Effective serum osmolality: 305 mOsm/kg
She receives appropriate fluid resuscitation and is started on intravenous insulin at 0.05 units/kg/hour. Four hours later, her blood glucose has fallen to 14 mmol/L (252 mg/dL), but the venous pH remains 7.02 and bicarbonate is 7 mmol/L. She remains clinically dehydrated but is hemodynamically stable.
What is the most appropriate next step in management?
A. Discontinue insulin infusion and begin subcutaneous rapid-acting insulin
B. Increase insulin infusion to 0.1 units/kg/hour to correct acidosis faster
C. Add dextrose to the intravenous fluids while continuing the insulin infusion
D. Administer intravenous sodium bicarbonate because severe acidosis persists
E. Reduce intravenous fluids to prevent cerebral edema
Correct answer & Explanation:
Correct Answer: C. Add dextrose to the intravenous fluids while continuing the insulin infusion
Explanation: Management of DKA in Children
The key principle in the management of DKA (diabetic ketoacidosis) is that treatment aims to resolve ketosis and metabolic acidosis, not simply to normalize blood glucose. When plasma glucose falls to approximately 250–300 mg/dL (14–17 mmol/L), dextrose should generally be added to the intravenous fluids. The insulin infusion must continue at the recommended rate until ketoacidosis has resolved, with adjustments to fluid dextrose concentration as needed to prevent hypoglycemia.
Insulin suppresses lipolysis and ketone production and promotes the clearance of ketones. Stopping insulin solely because glucose has normalized can allow ongoing ketogenesis and persistent or recurrent acidosis. These principles are emphasized in the ISPAD clinical practice guidelines for pediatric management of DKA and the Canadian Paediatric Society recommendations. Follow the local pediatric DKA protocol, as the precise glucose threshold and dextrose concentration may vary.
Why the Other Options Are Incorrect
A. Discontinue insulin infusion
Incorrect. Insulin should not be stopped simply because blood glucose has normalized. Continue intravenous insulin until ketoacidosis has resolved according to the applicable protocol, with transition to subcutaneous insulin appropriately timed to avoid a gap in insulin coverage.
B. Increase insulin infusion
Incorrect. Increasing insulin above the recommended protocol rate is not the routine response to falling glucose while acidosis persists. Instead, add or increase dextrose as necessary to allow insulin to continue safely. Excessive insulin can cause hypoglycemia and hypokalemia.
C. Add dextrose to the intravenous fluids while continuing the insulin infusion
Correct. This permits continued insulin administration to suppress ketogenesis and clear ketoacids while reducing the risk of hypoglycemia. Dextrose concentration and fluid composition should be adjusted according to serial glucose measurements, electrolytes, acid–base status, hydration, and the local protocol.
D. Administer sodium bicarbonate
Incorrect. Routine bicarbonate therapy is not recommended in pediatric DKA because benefit has not been demonstrated and treatment may contribute to hypokalemia and other complications. It is generally reserved for exceptional situations, such as life-threatening hyperkalemia or severe acidosis with compromised cardiac function, according to specialist guidance.
E. Reduce intravenous fluids
Incorrect. Fluids should be continued and adjusted according to the pediatric DKA protocol and the child’s clinical status. Reducing fluids solely because glucose has fallen is not appropriate. If cerebral injury is suspected, initiate urgent assessment and treatment—including hypertonic saline or mannitol when indicated—without waiting for neuroimaging.
Board Pearls
The endpoint of DKA treatment is resolution of ketosis and acidosis, not normalization of blood glucose alone.
Add dextrose when glucose approaches the protocol’s threshold—commonly around 250–300 mg/dL (14–17 mmol/L)—or earlier if glucose is falling rapidly.
Continue insulin while adjusting dextrose to prevent hypoglycemia until ketoacidosis resolves.
Assess resolution using the child’s clinical status and biochemical measures of acidosis and ketosis, as specified by the protocol.
Routine sodium bicarbonate is not recommended in pediatric DKA.
New headache, altered mental status, declining consciousness, bradycardia, hypertension, or cranial nerve abnormalities may indicate cerebral injury and require urgent action.
Find more High Yield MCQ on Pediatric Endocrinology and Genetics.
External Resources
ISPAD Clinical Practice Consensus Guidelines 2022: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State
Canadian Paediatric Society: Current Recommendations for Management of Paediatric Diabetic Ketoacidosis
Royal Children’s Hospital Melbourne: Diabetic Ketoacidosis Clinical Practice Guideline
References
- Glaser N, Fritsch M, Priyambada L, Rewers A, Cherubini V, Estrada S, et al. ISPAD clinical practice consensus guidelines 2022: diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes. 2022;23(7):835–856. doi: 10.1111/pedi.13406.
- Gripp KE, Trottier ED, Thakore S, Sniderman J, Lawrence S. Current recommendations for management of paediatric diabetic ketoacidosis. Paediatr Child Health. 2023;28(2):128–132. doi: 10.1093/pch/pxac119.
- Royal Children’s Hospital Melbourne. Clinical practice guideline: diabetic ketoacidosis. Available from: https://www.rch.org.au/clinicalguide/guideline_index/Diabetic_Ketoacidosis/.
