What is the management of Diabetic Ketoacidosis (DKA)?

From the Guidelines

Management of diabetic ketoacidosis (DKA) requires prompt intervention with intravenous fluids, insulin therapy, and electrolyte replacement, with the goal of restoring circulatory volume, resolving ketoacidosis, and correcting electrolyte imbalance and acidosis, as recommended by the most recent guidelines 1. The treatment approach should be individualized based on a careful clinical and laboratory assessment, taking into account the severity of the condition and the presence of any underlying causes, such as sepsis, myocardial infarction, or stroke.

Key Components of DKA Management

• Aggressive fluid resuscitation using isotonic saline at 15-20 mL/kg/hr for the first hour, then adjusted to 250-500 mL/hr based on hemodynamic status
• Insulin infusion at 0.1 units/kg/hr after initial fluid bolus, avoiding insulin boluses which can precipitate hypokalemia
• Potassium replacement, beginning when levels are below 5.2 mEq/L and serum potassium is at least 3.3 mEq/L, typically at 20-30 mEq/L in IV fluids
• Monitoring of blood glucose, electrolytes, and anion gap every 2-4 hours
• Identification and treatment of the precipitating cause, commonly infection, medication non-adherence, or new-onset diabetes

Transition to Subcutaneous Insulin

• Transition to subcutaneous insulin only when the anion gap normalizes, ketosis resolves, and the patient can eat
• Overlap IV insulin with subcutaneous insulin by 1-2 hours to prevent rebound hyperglycemia

Complications and Prevention

• Maintain vigilance for complications including cerebral edema, particularly in pediatric patients, and hypoglycemia during insulin therapy
• Prevention measures, such as gradual replacement of sodium and water deficits, and addition of dextrose to the hydrating solution once blood glucose reaches 250 mg/dL, may decrease the risk of cerebral edema in high-risk patients 1. The use of bicarbonate therapy is generally not recommended, as it has been shown to make no difference in the resolution of acidosis or time to discharge 1.

From the FDA Drug Label

Hyperglycemia (too much glucose in the blood) may develop if your body has too little insulin Hyperglycemia can be brought about by any of the following: Omitting your insulin or taking less than your doctor has prescribed. In patients with type 1 or insulin-dependent diabetes, prolonged hyperglycemia can result in DKA (a life-threatening emergency) The first symptoms of DKA usually come on gradually, over a period of hours or days, and include a drowsy feeling, flushed face, thirst, loss of appetite, and fruity odor on the breath. With DKA, blood and urine tests show large amounts of glucose and ketones. Heavy breathing and a rapid pulse are more severe symptoms If uncorrected, prolonged hyperglycemia or DKA can lead to nausea, vomiting, stomach pain, dehydration, loss of consciousness, or death. Therefore, it is important that you obtain medical assistance immediately.

The management of Diabetic Ketoacidosis (DKA) involves obtaining medical assistance immediately. Key points to consider include:

• Monitoring for symptoms of DKA, such as drowsy feeling, flushed face, thirst, loss of appetite, and fruity odor on the breath
• Blood and urine tests to show large amounts of glucose and ketones
• Severe symptoms include heavy breathing, rapid pulse, nausea, vomiting, stomach pain, dehydration, loss of consciousness, or death
• Treatment requires immediate medical attention to prevent serious complications or death 2

From the Research

Diagnosis and Management of Diabetic Ketoacidosis

• Diabetic ketoacidosis (DKA) is a serious complication of diabetes that requires prompt diagnosis and treatment 3.
• The diagnosis of DKA is confirmed by the presence of three criteria: elevated blood glucose levels or a family history of diabetes mellitus, high urinary or blood ketoacids, and a high anion gap metabolic acidosis 3.
• The mainstays of treatment for DKA include restoration of circulating volume, insulin therapy, electrolyte replacement, and treatment of any underlying precipitating event 3, 4.

Fluid Resuscitation in DKA Management

• Fluid resuscitation is a critical component of DKA management, with traditional guidelines recommending isotonic normal saline (NS) for initial volume replacement 5.
• However, recent studies suggest that large volumes of NS may lead to undesirable outcomes such as hyperchloremic metabolic acidosis 5, 6.
• Balanced electrolyte solutions (BES) may be a more physiological alternative to NS, with some studies showing faster resolution of DKA and improved clinical outcomes 5, 6.

Special Considerations in DKA Management

• Certain patient factors and comorbidities, such as pregnancy, renal disease, congestive heart failure, and older age, require special consideration and tailored management strategies 4.
• The use of sodium-glucose cotransporter-2 (SGLT2) inhibitors may also impact DKA treatment and requires careful attention 4.
• Guidelines often lack sufficient recommendations for managing DKA in patients with specific conditions and comorbidities, highlighting the need for further research and guidance 4, 7.

Treatment Outcomes and Complications

• Optimal treatment of DKA can improve patient outcomes and reduce morbidity and mortality 3, 7.
• However, suboptimal treatment and inconsistencies in management protocols can lead to increased risk of complications and poor outcomes 4, 5.
• Further research is needed to address knowledge gaps and controversies in DKA management and to guide the development of evidence-based treatment protocols 4, 6.