• Although insulin resistance has been shown to be a feature of diabetic ketoacidosis, in practice large doses of insulin are not required. A continuous low-dose intravenous infusion of 0.1 U/kg/h of soluble (unmodified) insulin is an effective and simple method for reversing the metabolic acidosis, and is associated with a lower incidence of hypoglycaemia and hypokalaemia than higher doses. A bolus of insulin is not necessary as large doses may cause a rapid reduction in blood glucose which may be undesirable.

• There are some who believe that younger children (especially the under 5s) are particularly sensitive to insulin and therefore require a lower dose of 0.05 U/kg/hour. There is no evidence to support the lower dose, and only the larger dose has been shown to correct hyperglycaemia and reverse ketosis.

• Insulin should not be added to the replacement fluid bag, but should be infused using a separate syringe pump, so that adjustments to fluid and insulin can be made independently.

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