What is the step-wise management of diabetic ketoacidosis (DKA) with hyperglycemia?

From the Guidelines

The management of diabetic ketoacidosis (DKA) with hyperglycemia, in this case, a blood glucose level of 32 mmol/L, requires a systematic approach focusing on fluid resuscitation, insulin therapy, electrolyte replacement, and addressing the underlying cause, as outlined in the most recent guidelines 1.

Step-wise Management

The following steps should be taken:

• Begin with aggressive intravenous fluid replacement using isotonic saline (0.9% NaCl) at 15-20 mL/kg/hr for the first hour, then adjust to 250-500 mL/hr based on hemodynamic status and hydration.
• Start insulin therapy with an IV insulin bolus of 0.1 units/kg followed by a continuous infusion at 0.1 units/kg/hr, aiming to reduce glucose by 50-75 mg/dL per hour, as recommended by recent studies 1.
• Once blood glucose reaches 200-250 mg/dL, switch to 5% dextrose with continued insulin to prevent hypoglycemia while treating the ketoacidosis.
• Replace potassium when levels are below 5.3 mEq/L, typically 20-30 mEq in each liter of IV fluid if renal function is adequate.
• Add bicarbonate therapy only for severe acidosis (pH < 6.9) using 100 mmol sodium bicarbonate in 400 mL water with 20 mEq KCl infused over 2 hours, although its use is generally not recommended unless absolutely necessary 1.

Monitoring and Assessment

• Monitor glucose hourly, electrolytes every 2-4 hours, and assess for resolution of DKA (glucose < 200 mg/dL, bicarbonate ≥ 15 mEq/L, pH > 7.3, and anion gap normalized).
• Investigate and treat precipitating factors such as infection, medication non-compliance, or acute illness. This approach addresses the three main pathophysiological disturbances in DKA: dehydration from osmotic diuresis, metabolic acidosis from ketone production, and electrolyte imbalances, particularly potassium depletion, and is supported by the most recent and highest quality evidence 1.

From the Research

Step-wise Management of Diabetic Ketoacidosis (DKA)

The management of DKA involves several key steps, including:

• Restoration of circulating volume and electrolyte replacement 2
• Correction of insulin deficiency to resolve metabolic acidosis and ketosis 2, 3
• Reduction of the risk of cerebral edema 2, 3
• Avoidance of other complications of therapy, such as hypoglycemia, hypokalemia, hyperkalemia, and hyperchloremic acidosis 2, 3, 4
• Identification and treatment of precipitating events 2

Fluid Replacement

• Intravenous fluid replacement is crucial in the management of DKA, with the goal of restoring circulating volume and correcting electrolyte imbalances 2, 5, 4
• The choice of fluid can affect the outcome, with balanced crystalloids potentially leading to faster resolution of DKA compared to saline 4
• The use of isotonic saline or half isotonic saline may be necessary in certain cases, such as hypernatremia 5

Insulin Therapy

• Insulin therapy is essential in the management of DKA, with the goal of correcting insulin deficiency and resolving metabolic acidosis and ketosis 2, 3, 6
• The use of low-dose insulin regimens, either by intramuscular injection or constant infusion, can be effective in managing DKA 3, 6
• The insulin infusion rate may need to be adjusted based on the patient's response to therapy, with higher doses potentially necessary in severe cases 3

Monitoring and Complications

• Close monitoring of the patient's vital signs, neurological status, and biochemical response to therapy is crucial in the management of DKA 2
• The risk of cerebral edema, hypoglycemia, and other complications must be carefully managed and treated promptly if they occur 2, 3, 4
• The use of protocols and guidelines can help standardize the management of DKA and reduce the risk of complications 2, 3, 4