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

From the Guidelines

The immediate management of Diabetic Ketoacidosis (DKA) requires aggressive fluid resuscitation, insulin therapy, electrolyte replacement, and addressing the underlying trigger, with the most recent guidelines from 2025 recommending a personalized approach for perioperative clinical management of individuals with DKA 1.

Key Components of DKA Management

• Aggressive fluid resuscitation using 0.9% normal saline at 15-20 mL/kg/hr (typically 1-1.5 L) in the first hour, then adjusting to 250-500 mL/hr based on hemodynamic status, as recommended in previous guidelines 1.
• Start continuous intravenous insulin at 0.1 units/kg/hr after the initial fluid bolus, with the option to use subcutaneous rapid-acting insulin analogs in uncomplicated DKA cases, as suggested by recent studies 1.
• Monitor blood glucose hourly, aiming for a decrease of 50-75 mg/dL per hour, and add dextrose (D5W or D10W) to the IV fluids when glucose reaches 200-250 mg/dL, while continuing insulin to clear ketones, as outlined in the 2024 guidelines 1.
• Replace potassium when levels are below 5.3 mEq/L and urine output is adequate, typically at 20-30 mEq per liter of IV fluid, to prevent hypokalemia and cardiac complications, as recommended in the 2003 guidelines 1.
• Administer bicarbonate only if pH is below 6.9, as its use is generally not recommended due to lack of significant difference in outcomes, as reported in recent studies 1.

Monitoring and Treatment

• Monitor electrolytes, glucose, and arterial blood gases every 2-4 hours to assess the effectiveness of treatment and adjust as needed, as recommended in the 2004 guidelines 1.
• Identify and treat the precipitating cause of DKA, which may include infection, medication non-adherence, or acute illness, to prevent recurrence and improve outcomes, as emphasized in the 2025 guidelines 1.

Pathophysiological Issues in DKA

• Dehydration from osmotic diuresis, which requires aggressive fluid resuscitation to restore circulatory volume and tissue perfusion, as outlined in the 2003 guidelines 1.
• Metabolic acidosis from ketone production, which requires insulin therapy to clear ketones and correct acidosis, as recommended in the 2024 guidelines 1.
• Electrolyte imbalances, particularly potassium depletion, which requires careful monitoring and replacement to prevent cardiac and skeletal muscle weakness, as recommended in the 2003 guidelines 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. With DKA, blood and urine tests show large amounts of glucose and ketones. Heavy breathing and a rapid pulse are more severe symptoms If uncorrected, prolonged hyperglycemia or DKA can lead to nausea, vomiting, stomach pain, dehydration, loss of consciousness, or death. Therefore, it is important that you obtain medical assistance immediately.

The immediate management of Diabetic Ketoacidosis (DKA) involves obtaining medical assistance immediately. The symptoms of DKA include:

• A drowsy feeling
• Flushed face
• Thirst
• Loss of appetite
• Fruity odor on the breath
• Heavy breathing
• Rapid pulse It is crucial to seek medical help promptly to prevent severe complications such as nausea, vomiting, stomach pain, dehydration, loss of consciousness, or death 2.

From the Research

Immediate Management of Diabetic Ketoacidosis (DKA)

The immediate management of DKA involves several key steps, including:

• Restoration of circulating volume and electrolyte replacement 3, 4, 5, 6
• Correction of insulin deficiency aiming at the resolution of metabolic acidosis and ketosis 3, 7, 4, 5, 6
• Reduction of risk of cerebral edema 7, 6
• Avoidance of other complications of therapy (hypoglycemia, hypokalemia, hyperkalemia, hyperchloremic acidosis) 3, 7, 6
• Identification and treatment of precipitating events 3, 4, 6

Treatment Guidelines

Treatment guidelines for DKA include:

• Adequate fluid replacement 3, 5, 6
• Low dose insulin therapy at frequent intervals 3, 7, 6
• Adequate potassium replacement from time of first insulin therapy with ECG monitoring 3, 6
• Bicarbonate replacement if pH less than 7.1 3, 5
• Broad spectrum antibiotics if infection is suspected 3
• Other supportive measures 3, 4, 6

Special Considerations

Special considerations in the management of DKA include:

• The role of phosphate and magnesium replacement is still controversial 3
• Awareness of complications during treatment, including cerebral edema, altered central nervous system oxygenation, vascular thrombosis, shock, myocardial infarction, pancreatitis, infection, inhalation of vomitus, overhydration, underhydration, hypoglycaemia, hyperkalemia, and hypokalemia 3, 7, 6
• The need for close monitoring and meticulous clinical care of the patient throughout the entire course of treatment 3, 4, 6