DKA · Pediatric

≈ 154.3 lb
Severity & dehydration

Moderate (pH 7.1–7.2 / HCO₃ 5–10)

Assumed dehydration

ISPAD: assume 5–7% (mild/moderate), 7–10% (severe). Avoid overestimating.

Initial fluid bolus (10 mL/kg 0.9% NaCl)
Each bolus / total (1×)
200 mL · total 200 mL

Single 10 mL/kg over 30–60 min if not in shock; repeat only for ongoing shock (max usually 2–3). Subtract from 48-h total.

48-hour fluid plan
Maintenance (Holliday-Segar) / 24 h1,500 mL
Deficit (7% × 20 kg)1,400 mL
Bolus already given− 200 mL
Total over 48 h4,200 mL
Infusion rate
88 mL/hr

Use 0.45–0.9% NaCl with K (and dextrose per glucose). Cap rate at 1.5–2 × maintenance to limit cerebral edema risk.

Insulin infusion (NO bolus)
Regular insulin gtt @ 0.1 U/kg/hr
2 U/hr

Start 1–2 h after IVF begins. 0.05 U/kg/hr in < 5 yr or pH > 7.15. Continue until pH > 7.30, HCO₃ > 15, AG closed — not just glucose normalized.

Current glucose → two-bag mix
Bag A only: 0.9% NaCl with KCl/K-phos (no dextrose).

Two-bag system: Bag A = 0.9% (or 0.45%) NaCl + K. Bag B = same fluid + D10 + K. Titrate the dextrose ratio to keep glucose 150–250 mg/dL while AG closes.

Potassium replacement
Add to each L of IVF
40 mEq/L
Add 20 mEq KCl + 20 mEq K-phos per L (40 mEq/L total).
⚠ Cerebral edema watch
  • Headache, recurrence of vomiting, HR drop, BP rise, GCS decline
  • Cushing's triad, cranial nerve palsy, abnormal pupils
  • Treat: 3% NaCl 2.5–5 mL/kg over 10–15 min or mannitol 0.5–1 g/kg; elevate HOB, reduce IVF rate by ⅓, intubate only for impending herniation.
Monitoring
  • Hourly: vitals, neuro checks, glucose, fluid in/out
  • q2h: VBG, BMP, glucose until AG closed and pH > 7.30
  • Transition to SC only after eating, AG closed, pH normal — overlap SC + gtt by 15–30 min for short-acting / 1–2 h for long-acting analog

Educational aid only — verify against your local pediatric DKA protocol (ISPAD 2022 / PECARN FLUID).