What is the management approach for Diabetic Ketoacidosis (DKA) as a continuous variable?

From the Guidelines

The management of Diabetic Ketoacidosis (DKA) as a continuous variable involves a stepwise approach focusing on fluid resuscitation, insulin therapy, electrolyte replacement, and addressing the underlying trigger, with the goal of restoring circulatory volume, resolving ketoacidosis, and correcting electrolyte imbalance and acidosis, as outlined in the 2024 standards of care in diabetes 1.

Key Components of DKA Management

• Initial treatment begins with aggressive intravenous fluid replacement using isotonic saline at 15-20 mL/kg/hr for the first hour, then 4-14 mL/kg/hr based on hemodynamic status.
• Insulin therapy should be initiated as a continuous IV infusion at 0.1 units/kg/hr after fluid resuscitation has begun, avoiding bolus insulin which can precipitate hypokalemia, with recent studies suggesting 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.
• Potassium replacement is critical when levels fall below 5.3 mEq/L, typically given as 20-30 mEq/L in IV fluids when urine output is confirmed.
• Bicarbonate therapy is generally not recommended unless pH is below 6.9, as several studies have shown that its use made no difference in the resolution of acidosis or time to discharge 1.

Monitoring and Adjustment

• Blood glucose should be monitored hourly, with a target reduction of 50-75 mg/dL/hr, transitioning from normal saline to 5% dextrose when glucose reaches 200-250 mg/dL to prevent hypoglycemia while continuing insulin to clear ketones.
• Frequent monitoring of electrolytes (every 2-4 hours), anion gap, and mental status is essential.
• The insulin infusion should continue until the anion gap normalizes and ketosis resolves, then overlap with subcutaneous insulin for 1-2 hours before discontinuing the infusion, with the goal of preventing recurrence of ketoacidosis and rebound hyperglycemia 1.

Approach to DKA Management

• DKA should be treated as a dynamic process requiring continuous adjustments rather than a binary condition, with resolution defined as glucose <200 mg/dL, bicarbonate ≥15 mEq/L, venous pH >7.3, and anion gap normalization.
• Individualization of treatment based on a careful clinical and laboratory assessment is needed, taking into account the severity of DKA, the presence of underlying conditions, and the patient's response to treatment 1.

From the Research

Management Approach for Diabetic Ketoacidosis (DKA) as a Continuous Variable

The management of DKA involves several key components, including:

• Restoration of circulating volume through fluid resuscitation 2
• Insulin therapy to reduce glucose levels and ketoacid production 3, 4, 5
• Electrolyte replacement to correct imbalances 4, 2
• Treatment of any underlying precipitating event, such as infection 4

Insulin Therapy

Insulin therapy is a crucial component of DKA management, with the goal of reducing glucose levels and ketoacid production. Studies have shown that subcutaneous insulin can be an effective alternative to intravenous insulin in mild and moderate cases of DKA 3. The use of low-dose insulin has also been recommended, based on numerous prospective randomized studies 5.

Fluid Resuscitation

Fluid resuscitation is a cornerstone of DKA management, with traditional guidelines recommending isotonic normal saline (NS) for initial volume replacement. However, recent studies suggest that large volumes of NS may lead to undesirable outcomes, such as hyperchloremic metabolic acidosis 6. The use of balanced crystalloids, such as lactated Ringers, may be a better option for initial resuscitation in DKA patients.

Monitoring and Treatment

Close monitoring of the patient's clinical and laboratory states is essential in DKA management, including frequent measurement of glucose, electrolyte, and ketone levels 4, 2. Treatment should be tailored to the individual patient's needs, with adjustments made as necessary to achieve optimal outcomes. Discharge plans should include appropriate choice and dosing of insulin regimens and interventions to prevent recurrence of DKA 4.

Prevention of DKA

Prevention of DKA is also an important aspect of management, with patient education programs focusing on adherence to insulin and self-care guidelines during illness, and improved access to medical providers 4. New approaches, such as extended availability of phone services, use of telemedicine, and utilization of public campaigns, can provide further support for the prevention of DKA 4.