What are the diagnostic criteria and treatment options for Diabetic Ketoacidosis (DKA)?

From the Guidelines

The primary treatment for Diabetic Ketoacidosis (DKA) involves fluid replacement, insulin therapy, and electrolyte management, with the goal of restoring circulatory volume, resolving ketoacidosis, and correcting electrolyte imbalance and acidosis, as recommended by the most recent guidelines 1. The diagnostic criteria for DKA include hyperglycemia, metabolic acidosis, and ketosis, with dehydration and electrolyte imbalance being common complications.

Initial Management

The initial management of DKA involves:

• IV fluids: Starting with 0.9% saline at 15-20 mL/kg/hr for the first hour, then adjusting based on hydration status.
• Insulin: Beginning with an IV insulin infusion at 0.1 units/kg/hr, with the option to use subcutaneous rapid-acting insulin analogs in uncomplicated cases 1.
• Potassium replacement: Adding 20-40 mEq/L of potassium to IV fluids if serum potassium is <5.2 mEq/L.
• Monitoring blood glucose hourly and adjusting insulin infusion to target a decrease of 50-75 mg/dL/hr.

Transition to Subcutaneous Insulin

Successful transition from intravenous to subcutaneous insulin requires administration of basal insulin 2–4 h before the intravenous insulin is stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia, as supported by recent studies 1. Additional considerations include:

• Monitoring electrolytes, especially potassium, closely.
• Addressing the underlying cause of DKA (e.g., infection, medication non-compliance).
• Considering bicarbonate therapy only if pH <6.9, although its use is generally not recommended due to lack of benefit in resolving acidosis or reducing time to discharge 1.

From the Research

Diagnostic Criteria for Diabetic Ketoacidosis (DKA)

• DKA is characterized by hyperglycemia, metabolic acidosis, and increased ketone bodies in the blood 2
• The diagnostic criteria for DKA include:
  • Hyperglycemia (typically > 250 mg/dL)
  • Metabolic acidosis (pH < 7.3)
  • Ketosis (presence of ketones in the blood or urine)
  • Dehydration and electrolyte imbalance

Treatment Options for DKA

• The mainstay of treatment for DKA is:
  • Fluid replacement to restore optimal volume status
  • Insulin therapy to reverse acidosis and reduce serum glucose levels
  • Potassium replacement to prevent hypokalemia
  • Treatment of any underlying precipitating cause
• Insulin therapy:
  • Low-dose intravenous infusion is the recommended mode of insulin delivery 2
  • Continuous intravenous infusion of regular insulin at a dose of 0.1 units/kg/h is commonly used 3
  • Some studies suggest that a bolus of insulin may not be necessary, and that a continuous infusion of insulin at a higher dose (0.14 units/kg/h) may be effective 4
• Fluid replacement:
  • Isotonic normal saline is the standard for initial fluid resuscitation 5
  • Balanced solutions may be used for subsequent fluid management 5
• Electrolyte replacement:
  • Potassium replacement is essential to prevent hypokalemia 2, 3, 6
  • Phosphate replacement may be necessary in some cases, but its use is controversial 2
• Other treatments:
  • Bicarbonate administration is generally not recommended, but may be considered in severe cases of acidosis (pH < 6.9) or during intubation 2, 5
  • Early initiation of oral nutrition may help reduce hospital length of stay 5

Special Considerations in Children and Adolescents

• DKA is a significant contributor to morbidity and mortality in children with type 1 diabetes 3
• Cerebral edema is a rare but potentially fatal complication of DKA in children, and its prevention and management are critical 3, 6
• Fluid infusion should precede insulin administration in children, and potassium replacement must be done early and sufficiently 6