What is the management of Diabetic Ketoacidosis (DKA)?

From the Guidelines

Management of diabetic ketoacidosis (DKA) requires prompt intervention with fluid resuscitation, insulin therapy, electrolyte replacement, and addressing the underlying trigger, with the most recent guidelines 1 recommending individualization of treatment based on a careful clinical and laboratory assessment. The primary goals of DKA management include restoration of circulatory volume and tissue perfusion, resolution of ketoacidosis, and correction of electrolyte imbalance and acidosis.

• Aggressive intravenous fluid replacement using 0.9% normal saline at 15-20 mL/kg/hr for the first hour (typically 1-1.5 L) is recommended, followed by adjustment to 250-500 mL/hr based on hemodynamic status.
• Insulin therapy should be started with an IV bolus of regular insulin at 0.1 units/kg, followed by continuous infusion at 0.1 units/kg/hr, as stated in the recent guidelines 1.
• Once glucose levels fall below 200-250 mg/dL, dextrose should be added to IV fluids (D5W or D10W) while continuing insulin to clear ketones.
• Potassium replacement is crucial when levels are below 5.3 mEq/L, aiming to maintain levels between 4-5 mEq/L, and phosphate and magnesium should be monitored and replaced as needed.
• Bicarbonate therapy is generally not recommended, except in cases of severe acidosis (pH < 6.9), as stated in the recent guidelines 1.
• Hourly checks of glucose, electrolytes, and venous pH are necessary until metabolic stability improves.
• Transition to subcutaneous insulin should only occur when ketoacidosis resolves (pH > 7.3, bicarbonate > 18 mEq/L, anion gap normalized), and the precipitating cause should be identified and treated, commonly infection, medication non-adherence, or new-onset diabetes, as recommended by the recent guidelines 1. Key considerations in DKA management include:
• Individualization of treatment based on clinical and laboratory assessment
• Aggressive fluid replacement and insulin therapy
• Electrolyte replacement and monitoring
• Identification and treatment of the underlying cause
• Transition to subcutaneous insulin when ketoacidosis resolves, as stated in the recent guidelines 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 2

From the Research

Diagnosis and Treatment of DKA

• Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 and type 2 diabetes, characterized by hyperglycemia, metabolic acidosis, and ketosis 3.
• The traditional diagnosis of DKA is based on the triad of hyperglycemia, metabolic acidosis, and elevated serum or urine ketones, but recent guidelines have de-emphasized hyperglycemia due to the increasing incidence of euglycemic DKA 3.
• Treatment of DKA involves fluid and electrolyte replacement, insulin therapy, and identification and treatment of the underlying precipitating cause 3, 4.

Fluid Management in DKA

• Traditional guidelines recommend isotonic normal saline (NS) for initial volume replacement in DKA patients 5.
• However, recent studies suggest that large volumes of NS may lead to undesirable outcomes such as hyperchloremic metabolic acidosis, and that balanced crystalloids like lactated Ringers may be a better choice 5.
• A study found that patients who received large volumes of NS had significantly longer ICU length of stay, prolonged insulin infusion, and a higher incidence of non-anion gap metabolic acidosis compared to those who received smaller volumes of NS or other fluids 5.

Insulin Therapy in DKA

• Insulin is typically administered intravenously in DKA patients, with an initial rate of about 0.1 u per kg per hour 6.
• The goal of insulin therapy is to reduce glucose levels and resolve ketosis, while also replacing electrolytes and fluids 6, 4.

Prevention and Education

• Prevention of DKA is crucial, and can be achieved through patient education programs that focus on adherence to insulin and self-care guidelines during illness 4.
• Clinicians should be aware of the occurrence of DKA in patients prescribed sodium-glucose co-transporter 2 inhibitors, and take steps to prevent and manage the condition 3, 4.
• Discharge plans should include appropriate choice and dosing of insulin regimens, as well as interventions to prevent recurrence of DKA 4.