Pediatric Diabetic Ketoacidosis Medication

  • Author: William H Lamb, MBBS, MD, FRCP(Edin), FRCP, FRCPCH; Chief Editor: Timothy E Corden, MD   more...
 
Updated: May 16, 2012
 

Medication Summary

The cornerstones of diabetic ketoacidosis management are fluid resuscitation, insulin administration, electrolyte monitoring and administration, and close observation to minimize the effects of cerebral edema.

As previously mentioned, continuous, low-dose IV insulin infusion is generally accepted as the safest and most effective method of insulin delivery for treating diabetic ketoacidosis.

Potassium chloride is commonly administered in electrolyte replacement therapy for diabetic ketoacidosis. IV bicarbonate replacement, in contrast, is justified only if the patient’s acidosis is severe enough to compromise cardiac contractility.

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Volume Expanders

Class Summary

The best outcomes have been achieved by using normal- or half-strength saline (ie, 0.9% or 0.45% sodium chloride) for first resuscitation and replacement. Slowly correcting the fluid deficit over 48 hours appears to be safer than rapid rehydration.

In a child with severe acidosis or compromised circulation, an initial resuscitation of 10-20mL/kg of isotonic sodium chloride solution (0.9%) can be administered over 30 minutes. Include this fluid as part of total replacement. After resuscitation, slowly correct the fluid deficit over 24-48 hours by providing normal maintenance fluids together with the calculated deficit. Administer isotonic sodium chloride solution until blood glucose levels have fallen to 250-300mg/dL (ie, 12-15mmol/L), at which time glucose-containing fluids should be introduced (eg, 5% glucose with 0.45% sodium chloride). Continue maintenance with dextrose saline until the child is eating and drinking normally.

Sodium chloride 0.9%

 

This agent is used for resuscitation and for dehydration associated with diabetic ketoacidosis. Calculate the fluid deficit by weight loss or clinical assessment.

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Antidiabetics, Insulins

Class Summary

Insulin is the only treatment that addresses the cause of diabetic ketoacidosis. Results from a prospective study of diabetic ketoacidosis suggested the risk of cerebral edema was higher in those who received immediate insulin treatment and starting insulin infusion one hour after fluid resuscitation has begun is suggested.

Intravenous insulin is probably the safest and most effective method for treating severe diabetic ketoacidosis. To reduce the risk of hypoglycemia, infuse the insulin through a Y-site or 3-way connector into the same intravenous line used for the maintenance fluid.

Only regular or fast-acting analogue insulins are suitable for intravenous use. Frequent, small subcutaneous doses of insulin lispro or insulin aspart have been used successfully to treat milder cases of diabetic ketoacidosis in which oral fluid replacement is possible. Once the child has recovered, administer subcutaneous insulin for further diabetes maintenance. Administer subcutaneous insulin at least 30 minutes before discontinuing the intravenous insulin.

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Insulin regular human (Humulin, Novolin)

 

This is a short-acting form of insulin traditionally used in the management of diabetic ketoacidosis, as it may be used intravenously. It stimulates the proper use of glucose by the cells and reduces blood sugar levels.

Have the pharmacy prepare the syringe at a concentration of 1 U/mL (ie, 50 U insulin qs with 0.9% sodium chloride to 50 mL). Because of the adsorption of insulin to the tubing and syringe, the actual amount of insulin administered may be less than the apparent amount. Adjust the doses according to the effect and not to the apparent insulin dose.

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Insulin lispro (Humalog)

 

Insulin lispro is a novel, short-acting, recombinant human insulin analogue that can be given intravenously to manage diabetic ketoacidosis. Insulin lispro is an insulin analog that has a more rapid onset and a shorter duration of action than does regular human insulin. Insulin lispro stimulates the proper use of glucose by the cells and reduces blood sugar levels.

Have the pharmacy prepare the syringe at a concentration of 1 U/mL (ie, 50 U insulin qs with 0.9% sodium chloride to 50 mL). Because of adsorption of insulin to the tubing and syringe, the actual amount of insulin administered may be less than the apparent amount. Adjust the doses according to the effect and not to the apparent insulin dose.

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Insulin aspart (NovoLog)

 

Insulin aspart is homologous with regular human insulin, with the exception of a single substitution of the amino acid proline with aspartic acid in position B28. It is produced by recombinant deoxyribonucleic acid (DNA) technology.

Insulin lowers blood glucose levels by stimulating peripheral glucose uptake, especially by skeletal muscle and fat, and by inhibiting hepatic glucose production. It inhibits lipolysis in the adipocyte, inhibits proteolysis, and enhances protein synthesis. Insulin is the principal hormone required for proper glucose use in normal metabolic processes.

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Electrolyte Supplements, Parenteral

Class Summary

Patients with diabetic ketoacidosis always have a total body deficit of potassium. After initial resuscitation, and provided serum or plasma levels are below 5 mEq/L or a good renal output has been maintained, add potassium to all replacement fluids.

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Potassium chloride

 

Potassium chloride is essential for the transmission of nerve impulses, contraction of cardiac muscle, maintenance of intracellular tonicity, skeletal and smooth muscles, and maintenance of normal renal function.

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Diuretics, Osmotic Agents

Class Summary

These agents are used for the emergency treatment of cerebral edema. Urgent treatment is required if neurologic status deteriorates and hypoglycemia is excluded; delaying beyond 10 minutes is associated with very poor outcomes.

Hypertonic saline (3% NaCl)

 

This is a hypertonic solution of sodium chloride that can be used as an alternative to mannitol in the treatment of cerebral edema caused by diabetic ketoacidosis.

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Mannitol (Osmitrol)

 

Mannitol is an osmotic diuretic traditionally used to treat cerebral edema. It is presented as a 10% or 20% solution for infusion, with the latter being preferable for pediatric use.

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Contributor Information and Disclosures
Author

William H Lamb, MBBS, MD, FRCP(Edin), FRCP, FRCPCH  Clinical Lecturer, Department of Child Health, The General Hospital, Bishop Auckland, UK

William H Lamb, MBBS, MD, FRCP(Edin), FRCP, FRCPCH is a member of the following medical societies: British Medical Association, British Society of Paediatric Endocrinology and Diabetes, International Society of Pediatric and Adolescent Diabetes, Royal College of Paediatrics and Child Health, and Royal College of Physicians

Disclosure: Roche Diabetes Care Honoraria Speaking and teaching; Medtronic Minimed Honoraria Speaking and teaching; Roche Diabetes Care Consulting fee Consulting

Chief Editor

Timothy E Corden, MD  Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin

Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, and Wisconsin Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

G Patricia Cantwell, MD, FCCM Professor of Clinical Pediatrics, Chief, Division of Pediatric Critical Care Medicine, University of Miami, Leonard M Miller School of Medicine; Medical Director, Palliative Care Team, Director, Pediatric Critical Care Transport, Holtz Children's Hospital, Jackson Memorial Medical Center; Medical Manager, FEMA, Urban Search and Rescue, South Florida, Task Force 2; Pediatric Medical Director, Tilli Kids – Pediatric Initiative, Division of Hospice Care Southeast Florida, Inc

G Patricia Cantwell, MD, FCCM is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Heart Association, American Trauma Society, National Association of EMS Physicians, Society of Critical Care Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Barry J Evans, MD Assistant Professor of Pediatrics, Temple University Medical School; Director of Pediatric Critical Care and Pulmonology, Associate Chair for Pediatric Education, Temple University Children's Medical Center

Barry J Evans, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Acknowledgments

The author would like to thank Debbie Matthews and Tim Cheetham for reading the manuscript and for all of their support.

References

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Glasgow Coma Scale, modified for age of verbal response.
A graphical representation of the electrocardiographic changes of hypokalemia.
A graphical representation of the electrocardiographic changes of hyperkalemia (due to overcorrection of potassium loss).
Diabetic ketoacidosis treatment and results chart (page 1 of 4).
Diabetic ketoacidosis treatment and results chart (page 2 of 4).
Diabetic ketoacidosis treatment and results chart (page 3 of 4).
Diabetic ketoacidosis treatment and results chart (page 4 of 4).
Carbs for Kids-Count Them In: The Constant Carbohydrates Diet.
Diabetes Sick Day Rules.
Taking Diabetes Back to School.
Table 1. Clinical Assessment of Dehydration
Mild (< 3%) Moderate



(3-8%)



Severe (8%) and



Shock (>10%)



AppearanceThirsty, alertThirsty, lethargicDrowsy, cold
Tissue turgorNormalAbsentAbsent
Mucous membranesMoistDryVery dry
Blood pressureNormalNormal or lowLow for age
PulseNormalRapidRapid and weak
EyesNormalSunkenGrossly sunken
Anterior fontanelleNormalSunkenGrossly sunken
Table 2. Suggested Daily Maintenance Fluid Replacement Rates
Weight Infusion rate
0-12.9 kg80 mL/kg/24 h
13-19.9 kg65 mL/kg/24 h
20-34.9 kg55 mL/kg/24 h
35-59.9 kg45 mL/kg/24 h
Adult (>60 kg)35 mL/kg/24 h
Table 3. Infusion Rates of Potassium Chloride
Serum/Plasma K+ (mEq/L) Potassium Chloride (KCL) Dose in Infusion Fluids
< 2.5 mEq/LCarefully monitored administration of 1 mEq/kg body weight by separate infusion over 1 h
2.5-3.5 mEq/L40 mEq/L
3.5-5 mEq/L20 mEq/L
5-6 mEq/L10 mEq/L (optional)
Over 6 mEq/LStop K+ and repeat level in 2 h
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