1. Obtain two IV sites; one for IV fluids and Insulin drip and the other for lab draws.
  2. Bolus with 0.9% normal saline 10-20 ml/kg (if indicated).
  3. Obtain rapid bedside blood glucose, electrolytes and ABG via I-Stat analysis every hour.
  4. Begin Insulin drip
    1. Mix 100 units regular insulin in 100 ml of NS to make a solution of 1unit/ml.
    2. Clear tubing with 50 ml of solution to saturate tubing binding sites.
    3. Begin insulin drip at 0.1units/kg/hr. Lower dose (0.05 unit/kg/hr) used in younger children to avoid rapid drop in glucose.
    4. Desired rate of decline in serum glucose is 80-100 mg/dl per hour. Check glucocheck hourly.
  5. Add dextrose to IVF when serum glucose levels fall to 250-300.
  6. After fluid resuscitation, start maintenance fluids
    1. NS at 1.5X maintenance rate
    2. Add 20 mEq/L KCl to each liter of IV fluid when K+ < 5.5 mEq/L if possible
  7. Observe for cerebral edema.
    1. Consider mannitol (Osmitrol): 0.5-1 g/kg IV over 30 minutes for patients with changes in level of consciousness, confusion, pupil inequality, posturing or seizures, measure glucose and correct if hypoglycemic.
  8. Intubate for neurologic deterioration and signs & symptoms of herniation. (See: Rapid Sequence Induction and Intubation)
  9. DO NOT treat with sodium bicarbonate.
  10. DO NOT treat with IV insulin bolus.


  1. BSPED recommended guidelines on diabetic ketoacidosis 2004 (

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