What is the initial management of Diabetic Ketoacidosis (DKA)?

From the Guidelines

The initial management of Diabetic Ketoacidosis (DKA) should focus on fluid resuscitation, insulin therapy, electrolyte replacement, and identifying the underlying trigger, with the most recent guidelines from 2024 (1) recommending aggressive intravenous fluid resuscitation and continuous intravenous insulin infusion. The management goals include restoration of circulatory volume and tissue perfusion, resolution of ketoacidosis, and correction of electrolyte imbalance and acidosis. Key steps in the initial management include:

• Aggressive intravenous fluid resuscitation using isotonic saline (0.9% NaCl) at 15-20 mL/kg/hr for the first hour, then adjusting based on hemodynamic status and hydration.
• Starting continuous intravenous insulin infusion at 0.1 units/kg/hr after the initial fluid bolus, with recent studies suggesting the addition of a low dose of basal insulin analog to prevent rebound hyperglycemia (1).
• Monitoring blood glucose hourly, aiming for a decrease of 50-75 mg/dL per hour, and adding dextrose to IV fluids when glucose reaches 200-250 mg/dL.
• Replacing potassium when levels are below 5.3 mEq/L and urine output is adequate, typically at 20-30 mEq per liter of IV fluid, and monitoring electrolytes (potassium, phosphate, magnesium) every 2-4 hours initially.
• Avoiding bicarbonate therapy unless pH is below 6.9, as its use is generally not recommended (1). Throughout treatment, it is crucial to monitor vital signs, mental status, fluid input/output, and laboratory values (glucose, electrolytes, venous pH, anion gap) regularly to address the three main pathophysiological issues in DKA: dehydration from osmotic diuresis, insulin deficiency leading to hyperglycemia and ketogenesis, and electrolyte imbalances that can cause life-threatening complications.

From the Research

Initial Management of Diabetic Ketoacidosis (DKA)

The initial management of DKA involves several key components, including:

• Fluid and electrolyte replacement to restore circulating volume and correct electrolyte imbalances 2, 3
• Insulin therapy to reduce glucose levels and inhibit ketone production 4, 5
• Treatment of any underlying precipitating event, such as infection or non-adherence to insulin therapy 4, 6
• Close monitoring of the patient's clinical and laboratory conditions to adjust therapy and identify complications 4, 5

Fluid Resuscitation

Fluid resuscitation is a critical component of DKA management, and the choice of fluid can impact outcomes. Studies have shown that:

• Balanced electrolyte solutions (BES) may be more effective than 0.9% saline in resolving DKA, with a faster resolution time and improved electrolyte balance 2
• Large-volume resuscitation with isotonic normal saline (NS) may be associated with increased ICU length of stay, prolonged insulin infusion, and a higher incidence of non-anion gap metabolic acidosis 3

Electrolyte Replacement

Electrolyte replacement is also crucial in DKA management, as patients often present with electrolyte imbalances. Key electrolytes to monitor and replace include:

• Sodium and chloride, which can become imbalanced due to fluid resuscitation and insulin therapy 2, 3
• Potassium, which can become depleted due to insulin therapy and electrolyte imbalances 4, 5
• Phosphate, which can become depleted due to insulin therapy and electrolyte imbalances 4, 6

Insulin Therapy

Insulin therapy is a mainstay of DKA treatment, and is typically administered intravenously. Key considerations include:

• The dose and rate of insulin administration, which should be tailored to the individual patient's needs 4, 5
• The type of insulin used, which can impact the risk of hypoglycemia and other complications 4, 6