Ketoacidosis, hour six

A 9-year-old with new diabetes in ketoacidosis, six hours into fluids and an insulin infusion. The glucose is falling beautifully. Setting: Pediatric high-dependency bed.

1. Hour 4

   Glucose 19 (from 34), pH 7.18 (from 7.05), potassium 3.9, sodium 133 corrected to about 136.

   HR118RR26BP106/68SpO299%T36.9

   Mental status

   Alert, complaining that he is thirsty and bored.

   Respiratory effort

   Deep breathing, less than on arrival.

   Perfusion

   Refill 2 seconds, warm.

   Urine

   Passing urine; potassium being replaced in the fluids.

   Read hour 4 for a 9-year-old.

   Responding as expected: glucose falling at a safe rate, potassium holding, corrected sodium stable; observations continueThe glucose is falling too slowly for a 9-year-old on this protocol; double the insulin infusion rateThe sodium of 133 is a true hyponatremia from the fluids; restrict the rate by a third and recheck in two hoursStop the potassium in the fluids now that it is normal, to avoid overshooting into hyperkalemia

Educational simulation of a fictitious child. Vital sign reads come from the platform’s age-band reference layer (PALS 2020 teaching ranges) and are never a substitute for institutional early-warning scores or clinical judgement.