A 9-year-old girl in diabetic ketoacidosis receives fluid resuscitation followed by an intravenous insulin infusion at 0.05 units/kg/hour. Two hours later blood glucose has fallen from 480 to 260 mg/dL, but pH remains 7.12 with bicarbonate 9 mEq/L. What is the correct next step?

• A Stop the insulin infusion since glucose is near target
• B Add 5 percent dextrose to the intravenous fluids and continue insulin ✓
• C Double the insulin infusion rate to clear ketones faster
• D Give subcutaneous basal insulin and discontinue all intravenous therapy

Explanation

Insulin must continue until ketoacidosis resolves, because it suppresses ketogenesis and lipolysis; stopping it once glucose normalizes leaves ongoing acidosis. When glucose approaches 250 to 300 mg/dL, dextrose is added so insulin can be continued safely. Doubling the rate accelerates glucose fall and raises cerebral oedema risk without clearing ketones faster. Switching to subcutaneous insulin is deferred until pH normalizes, appetite returns, and the child can eat.

Reference: ISPAD Clinical Practice Consensus Guidelines, 2022 ed.

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Written and medically reviewed by the StethoPrep medical team.