Management of Diabetic Ketoacidosis in Adolescents

Initial Diagnostic Workup and Management

The American Diabetes Association recommends immediate aggressive fluid resuscitation with isotonic saline at 15-20 mL/kg/hour for the first hour, followed by continuous IV regular insulin at 0.1 units/kg/hour once serum potassium is ≥3.3 mEq/L, while conducting comprehensive laboratory evaluation and identifying precipitating factors 1
Initial laboratory studies should include blood glucose, arterial blood gas (or venous pH), serum ketones, electrolytes with calculated anion gap, serum osmolality, complete blood count with differential, blood urea nitrogen/creatinine, urinalysis with urine ketones, and electrocardiogram to assess for cardiac effects of electrolyte abnormalities 1, 2
Diagnostic criteria confirmation requires blood glucose >250 mg/dL, arterial pH <7.3, serum bicarbonate <15 mEq/L, and presence of ketonemia or ketonuria 1

The American College of Clinical Endocrinologists recommends beginning with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour during the first hour to restore circulatory volume and tissue perfusion 1, 2, 3
Potassium assessment before insulin is critical, and insulin should not be started if serum potassium is <3.3 mEq/L 1, 2
Target glucose decline should be 50-75 mg/dL per hour, and if glucose does not fall by 50 mg/dL in the first hour, verify adequate hydration and double the insulin infusion rate hourly until achieving steady decline 1, 2

After initial resuscitation, adjust fluid composition based on hydration status, serum electrolyte levels, and urine output 1
When glucose reaches 200-250 mg/dL, switch to 5% dextrose with 0.45-0.75% saline while continuing insulin infusion 1, 2, 3
Draw blood every 2-4 hours to measure serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH 1, 2, 3

DKA is resolved when glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L 1, 2, 3
Once DKA is resolved and the patient can tolerate oral intake, administer basal insulin (glargine or detemir) subcutaneously 2-4 hours before stopping IV insulin, and start multiple-dose insulin regimen combining short/rapid-acting insulin with meals and intermediate/long-acting basal insulin 1, 2, 3

In an obese 15-year-old with DKA, manage with insulin therapy while obtaining diabetes autoantibodies, C-peptide levels, and family history assessment to distinguish between type 1 and type 2 diabetes 1, 2, 4
Common triggers in adolescents include new diagnosis of diabetes, infection, insulin omission/non-adherence, and concurrent illness 1, 2
Bicarbonate administration is not recommended if pH >6.9-7.0, as it may worsen ketosis, cause hypokalemia, and increase cerebral edema risk 1, 3

Before discharge, ensure outpatient diabetes care provider is identified, patient/family education on insulin administration, glucose monitoring, recognition/treatment of hypoglycemia and hyperglycemia, and sick-day management 1, 5
Follow-up appointment should be scheduled within 1-2 weeks, and prescriptions should be filled and reviewed before leaving the hospital 5, 6