How to manage a diabetic ketoacidosis (DKA) patient admitted from the emergency department (ED) with a now-closed glucose gap?

From the Guidelines

The management of a diabetic ketoacidosis (DKA) patient with a closed glucose gap requires careful transition from intravenous to subcutaneous insulin, ensuring metabolic stability and preventing recurrence of ketoacidosis, as recommended by the most recent guidelines 1. To achieve this, several key steps should be taken:

• Continue intravenous insulin until the anion gap closes (typically <12 mEq/L) and bicarbonate normalizes (>18 mEq/L), even though the glucose gap has closed, to ensure complete resolution of ketoacidosis.
• Start subcutaneous insulin 2-4 hours before discontinuing the insulin infusion, as suggested by recent studies 1, to prevent rebound hyperglycemia.
• Administer basal insulin, such as glargine or detemir, along with rapid-acting insulin, like lispro, aspart, or regular insulin, before meals, with a total daily insulin dose typically ranging from 0.5-0.8 units/kg/day.
• Monitor blood glucose every 4-6 hours, electrolytes (particularly potassium), and acid-base status to ensure metabolic stability.
• Maintain intravenous fluids until the patient can adequately hydrate orally, typically transitioning from normal saline to half-normal saline as glucose levels decrease.
• Address any precipitating factors, such as infection or medication non-adherence, to prevent recurrence of DKA. It is also important to note that the use of bicarbonate in patients with DKA is generally not recommended, as it has been shown to make no difference in the resolution of acidosis or time to discharge 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.

The management of Diabetic Ketoacidosis (DKA) admission from the ED with a now-closed glucose gap is not directly addressed in the provided drug label. Key points to consider in managing DKA include:

• Insulin therapy
• Fluid replacement
• Electrolyte management However, the provided label does not give specific instructions on how to manage DKA in this context. 2

From the Research

Management of DKA Admission

To manage a diabetic ketoacidosis (DKA) patient admitted from the emergency department (ED) with a now-closed glucose gap, the following steps can be taken:

• Fluid repletion and insulin administration are mainstays of DKA treatment, serving to restore normal hemodynamic status while decreasing the metabolic acidosis 3
• Careful monitoring of glucose concentrations, vital signs, and electrolytes is essential to prevent complications arising from the treatment of DKA 3
• Coordination of fluid resuscitation, insulin therapy, and electrolyte replacement through feedback obtained from timely patient monitoring and knowledge of resolution criteria is crucial 4
• Awareness of special populations, such as patients with renal disease presenting with DKA, is important 4

Treatment and Monitoring

• Reversing metabolic derangements, correcting volume depletion, electrolyte imbalances, and acidosis while concurrently treating the precipitating illness is necessary 5
• Different society guidelines have inconsistencies in their recommendations, and some aspects of treatment are not precise enough or have not been thoroughly studied 5
• Controversies in DKA management include optimal fluid resuscitation, rate and type of insulin therapy, potassium and bicarbonate replacement 5
• Monitoring for complications and adjusting treatment accordingly is vital 6

Protocol Implementation

• Implementing a standardizing ED DKA management protocol can reduce variability and improve safety 6
• Adherence to the protocol can be improved through audit and feedback 6
• Reductions in variability and improvements in measures of safety can be achieved through protocol implementation 6
• Early diagnosis and management are paramount to improve patient outcomes, and the mainstays of treatment include restoration of circulating volume, insulin therapy, electrolyte replacement, and treatment of any underlying precipitating event 7