With the rise in obesity in children we frequently see patients with a mixed picture of extreme hyperglycemia (>600 mg/dL) and mild ketosis, with or without mental status changes.
These patients are at high risk for cerebral edema due to osmolar shift. Unlike classic diabetic ketoacidosis (DKA), they are often profoundly hypovolemic and require more volume resuscitation. Insulin infusions are given at a lower rate to avoid rapid osmolar shift. Don't forget to correct serum sodium levels (add 1 to 2 mEq Na for every every 100 mg/dL increase in serum glucose over 100).