What is the management of diabetic ketoacidosis (DKA)?

From the Guidelines

The management of diabetic ketoacidosis (DKA) should prioritize restoration of circulatory volume and tissue perfusion, resolution of ketoacidosis, and correction of electrolyte imbalance and acidosis, with individualization of treatment based on a careful clinical and laboratory assessment 1. The primary goals of DKA management include:

• Restoration of circulatory volume and tissue perfusion
• Resolution of ketoacidosis
• Correction of electrolyte imbalance and acidosis
• Treatment of any correctable underlying cause of DKA, such as sepsis, myocardial infarction, or stroke In critically ill and mentally obtunded individuals with DKA, continuous intravenous insulin is the standard of care 1. Key considerations in DKA management include:
• Administration of basal insulin 2–4 h before the intravenous insulin is stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia 1
• The use of a low dose of basal insulin analog in addition to intravenous insulin infusion may prevent rebound hyperglycemia without increased risk of hypoglycemia 1
• No significant difference in outcomes for intravenous human regular insulin versus subcutaneous rapid-acting analogs when combined with aggressive fluid management for treating mild or moderate DKA 1
• The use of bicarbonate in people with DKA is generally not recommended, as it made no difference in the resolution of acidosis or time to discharge 1

From the Research

Management of Diabetic Ketoacidosis (DKA)

The management of DKA involves several key components, including:

• Restoration of optimal volume status
• Reversal of acidosis
• Reduction of serum glucose levels
• Replacement of specific electrolytes in a timely manner
• Institution of appropriate therapy for any precipitating cause
• Careful monitoring of the patient's biochemical, physical, and mental parameters to allow adjustment in therapy as necessary 2

Treatment Approaches

The mainstay of treatment for DKA is appropriate fluid and insulin therapy, with low-dose intravenous infusion being the accepted mode of insulin delivery 2. Potassium replacement is almost always necessary, often requiring massive amounts of this ion due to total body depletion seen with the development of ketoacidosis 2.

• Fluid resuscitation: to restore optimal volume status
• Insulin therapy: to reduce serum glucose levels and reverse acidosis
• Electrolyte replacement: to replace specific electrolytes, such as potassium and phosphate
• Monitoring: to track the patient's progress and adjust therapy as necessary 3, 4, 5

Controversies and Considerations

There are still controversies regarding certain aspects of DKA management, including:

• Optimal fluid resuscitation
• Rate and type of insulin therapy
• Potassium and bicarbonate replacement
• Management of special patient factors and comorbidities, such as pregnancy, renal disease, and congestive heart failure 3
• Use of sodium-glucose cotransporter-2 (SGLT2) inhibitors and their impact on DKA treatment 3

Prevention and Education

Prevention of DKA is crucial, and patient education should include information on:

• How to adjust insulin during times of illness
• How to monitor glucose and ketone levels
• The importance of medication compliance
• Recognition of early symptoms of DKA to prevent it 2, 6