II. Management: Phase 1 - Fluids in Children (Emergent)

  1. Stabilize shock and Coma states first!
  2. Correct Volume Deficit
    1. Initial
      1. Give 10-20 cc/kg NS bolus over first 45 minutes
      2. Repeat fluid bolus until shock corrected
    2. Next
      1. Fluid deficit replacement distributed evenly over 48 hour period
      2. Start with NS and transition to 1/2 NS over th subsequent 8-10 hours
      3. Rate: 5 ml/kg/hour (1.5 times maintenance)
      4. Use fluids without dextrose (1/2NS) until Serum Glucose <250 mg/dl, then use D5 1/2NS
        1. Could also continue NS until Serum Glucose <200-250 mg/dl, then transition to D5 1/2 NS
  3. Precautions
    1. Do not drop Serum Osmolality (calc) >3 mOsms/hour
      1. Diabetic Ketoacidosis Related Cerebral Edema
      2. Risk of cerebral edema
    2. Slow replacement if Fluid Overload risk (and consider close hemodynamic monitoring)
      1. Congestive Heart Failure
      2. Chronic Renal Insufficiency
    3. Follow Intake and output closely

III. Management: Phase 2 - Acidosis, electrolytes in children

  1. Potassium Replacement
    1. Precautions
      1. Hypokalemia must be corrected prior to Insulin
      2. Hold Insulin until Potassium >2.5 meq/L in children
    2. Prerequisites
      1. Electrocardiogram without signs of Hyperkalemia
      2. Adequate urine output
    3. Administration: Children
      1. Serum Potassium <2.5 meq/L
        1. Do not administer Insulin until Potassium >2.5 meq/L
        2. KCl 1 meq/kg (to 40 meq) IV over 1 hour, recheck
          1. This is maximum IV Potassium rate!
          2. Requires cardiac monitoring
          3. Requires hourly recheck of Serum Potassium
      2. Serum Potassium 2.5 to 3.5 meq/L
        1. Give 40-60 meq/L in IV solution
        2. Recheck Serum Potassium hourly
        3. Continue replacement until Potassium >3.5 meq/L
      3. Serum Potassium 3.5 to 5.0 meq/L
        1. Add 30-40 meq Potassium per liter to IV fluids
      4. Serum Potassium >5.0 meq/L
        1. Do not administer any IV Potassium
        2. Monitor every 1 hour until <5.0 meq/L
  2. Phosphate Replacement
    1. Indications
      1. Serum Phosphorus < 0.5-1.0 mg/dl (Severe Depletion)
      2. Controversial - May not be required
      3. Consider if cardiopulmonary adverse affects
    2. Contraindications
      1. Renal Insufficiency
    3. Administration
      1. Determine Potassium Replacement as above
      2. Replace part of Potassium with Potassium phosphate
        1. Potassium Phosphate: Replace one third Potassium
        2. Potassium Chloride: Replace two thirds Potassium
  3. Magnesium Replacement
    1. Indications
      1. Symptomatic Hypomagnesemia (Magnesium <1 meq/L)
    2. Administration
      1. MgSO4 50%: 0.2 ml/kg/day IM divide in 3 doses
  4. Sodium Bicarbonate Replacement
    1. Indications
      1. ABG pH < 7.0 after initial hour of hydration
      2. Other contributing factors
        1. Shock or Coma
        2. Severe Hyperkalemia
    2. Administration
      1. See Sodium Bicarbonate in Severe Metabolic Acidosis
      2. Add 2 mEq/kg NaCl to NS for a final solution with no more than 155 mEq/L Sodium
      3. Administer solution over 1 hour

IV. Management: Phase 3 - Glucose control in children

  1. Initial Insulin Dosing
    1. Intravenous protocol
      1. IV Regular Insulin drip starting at 0.1 unit/kg/hour
    2. Subcutaneous protocol (if IV not available)
      1. Bolus: Regular Insulin 0.3 units/kg SC
      2. Maintenance
        1. Per 1 Hour: 0.1 units/kg or
        2. Per 2 Hours: 0.15 to 0.20 units/kg
  2. Maintenance
    1. Continue Insulin Infusion until acidosis resolves
  3. When pH>7.3 and serum bicarbonate >15 mEq/L
    1. Decrease Insulin Infusion to 0.05 units/kg/hour
    2. Continue Insulin Infusion until SC Insulin started
  4. Glucose and electolyte monitoring
    1. Check bedside Glucose every 30 min to 2 hours until stable
    2. Add dextrose to replacement fluids when Serum Glucose <250 mg/dl (see Fluids above)
    3. Recheck basic metabolic panel every 2-4 hours until stable (see labs below)
  5. Initiate subcutaneous Insulin Dosing
    1. Known diabetic
      1. Restart prior program and readjust Insulin
    2. New patient: Determine Insulin requirements
      1. Regular 0.1 to 0.25 units per kg Regular Insulin every 6-8 hours or
      2. Divide 0.5 to 1 unit/kg/day into twice daily regimen of short and long acting Insulin
        1. AM (66%): Give 1/3 short acting and 2/3 intermediate to long actng Insulin
        2. PM (33%): Give 1/2 short acting and 1/2 intermediate to long actng Insulin

V. Monitoring: Labs every 2-4 hours until stable

  1. Serum electrolytes
  2. Serum Creatinine
  3. Blood Urea Nitrogen
  4. Serum Glucose (checked every 30 min to hour as above)

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