What is the management of Diabetic Ketoacidosis (DKA)?

From the Guidelines

Diabetic ketoacidosis (DKA) management should prioritize fluid resuscitation, insulin therapy, and electrolyte replacement, with the goal of restoring circulatory volume, resolving ketoacidosis, and correcting electrolyte imbalances, as recommended by the most recent guidelines 1.

Key Management Strategies

• Begin with aggressive intravenous fluid replacement using normal saline at 15-20 mL/kg/hr for the first hour, then reduce to 250-500 mL/hr based on hemodynamic status.
• Start continuous intravenous insulin at 0.1 units/kg/hr after initial fluid bolus, avoiding insulin boluses, as this has been shown to be effective in resolving ketoacidosis 1.
• Monitor blood glucose hourly, aiming for a decrease of 50-75 mg/dL per hour, and adjust insulin dosage accordingly.
• Replace potassium when levels are below 5.3 mEq/L and urine output is adequate, typically 20-30 mEq per liter of IV fluid.
• Monitor electrolytes, particularly potassium, phosphate, and magnesium, every 2-4 hours.
• Bicarbonate therapy is generally not recommended unless pH is below 6.9, as it has not been shown to improve outcomes 1.

Transition to Subcutaneous Insulin

• Transition to subcutaneous insulin when the patient is clinically improved, ketoacidosis has resolved (anion gap normalized, pH >7.3, bicarbonate >18 mEq/L), and the patient can eat.
• Give subcutaneous insulin 1-2 hours before stopping IV insulin to prevent rebound hyperglycemia, as recommended by recent studies 1.

Identifying and Treating the Precipitating Cause

• Identify and treat the precipitating cause, commonly infection, medication non-adherence, or new-onset diabetes.
• Close monitoring for cerebral edema is essential, particularly in pediatric patients.

Recent Guidelines and Recommendations

• The most recent guidelines recommend individualization of treatment based on a careful clinical and laboratory assessment, and emphasize the importance of addressing the underlying cause of DKA 1.
• Recent studies have reported that the administration of a low dose of basal insulin analog in addition to intravenous insulin infusion may prevent rebound hyperglycemia without increased risk of hypoglycemia 1.

From the Research

Diagnosis of Diabetic Ketoacidosis

• Diabetic ketoacidosis (DKA) is diagnosed by the presence of hyperglycemia, metabolic acidosis, and elevated serum or urine ketones 2, 3, 4, 5.
• The diagnosis can be confirmed when all three criteria are present: elevated blood glucose levels or a family history of diabetes mellitus, the presence of high urinary or blood ketoacids, and a high anion gap metabolic acidosis 5.
• Recent guidelines have de-emphasized hyperglycemia due to the increasing incidence of euglycemic DKA 4.

Management of Diabetic Ketoacidosis

• The mainstays of treatment include restoration of circulating volume, insulin therapy, electrolyte replacement, and treatment of any underlying precipitating event 2, 3, 5.
• Fluid resuscitation, typically with isotonic saline, is crucial in the initial management of DKA 3, 6.
• Insulin therapy, usually low-dose, is essential in the treatment of DKA 3, 4, 6.
• Electrolyte replacement, particularly potassium, is vital to prevent complications 2, 3, 6.
• Treatment of precipitating causes, such as infections, is also important in the management of DKA 4, 6.

Prevention and Complications

• Prevention strategies include patient education, identifying diabetes before DKA develops, and ensuring uninterrupted access to therapies for diabetes 4, 6.
• Complications of DKA, such as cerebral edema, can be life-threatening and require prompt recognition and treatment 3, 6.
• Special patient factors, such as pregnancy, renal disease, and congestive heart failure, require tailored management strategies 6.
• The use of sodium-glucose cotransporter-2 inhibitors can increase the risk of DKA and euglycemic DKA 4, 6.