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Obtain two IV sites; one for IV fluids and Insulin drip and the other for lab draws.
Bolus with 0.9% normal saline 10-20 ml/kg (if indicated).
Obtain rapid bedside blood glucose, electrolytes and ABG via I-Stat analysis every hour.
Begin Insulin drip
Mix 100 units regular insulin in 100 ml of NS to make a solution of 1unit/ml.
Clear tubing with 50 ml of solution to saturate tubing binding sites.
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.
Desired rate of decline in serum glucose is 80-100 mg/dl per hour. Check Gluco-Check hourly.
Add dextrose to IVF when serum glucose levels fall to 250-300.
After fluid resuscitation, start maintenance fluids
NS at 1.5X maintenance rate
Add 20 mEq/L KCl to each liter of IV fluid when K+ < 5.5 mEq/L if possible
Observe for cerebral edema.
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.