What is the assessment and plan for a patient presenting with Diabetic Ketoacidosis (DKA)?

From the Guidelines

The assessment and plan for a patient with Diabetic Ketoacidosis (DKA) involves immediate stabilization with intravenous fluids, insulin therapy, and electrolyte management, with the goal of restoring circulatory volume, resolving ketoacidosis, and correcting electrolyte imbalance and acidosis, as recommended by the most recent guidelines 1.

Key Components of DKA Management

• Initial fluid replacement with 1-2 liters of normal saline in the first hour, followed by 250-500 mL/hour based on hydration status
• Insulin infusion at 0.1 units/kg/hour after fluid resuscitation has begun, with regular monitoring of blood glucose every 1-2 hours
• Potassium replacement when levels fall below 5.3 mEq/L, typically giving 20-30 mEq per liter of IV fluid
• Bicarbonate therapy generally reserved for severe acidosis (pH < 6.9)
• Transition to subcutaneous insulin only when the patient is clinically improved, metabolic acidosis is resolving, and the patient can eat, typically involving administration of basal insulin 2-4 hours before stopping the insulin infusion 1

Monitoring and Adjustments

• Regular monitoring of vital signs, mental status, fluid balance, electrolytes, and anion gap
• Adjustments to insulin and fluid therapy based on patient response and laboratory results
• Consideration of underlying causes of DKA, such as sepsis, myocardial infarction, or stroke, and treatment of these conditions as needed

Recent Guidelines and Recommendations

• The use of bicarbonate in patients with DKA is generally not recommended, as it has not been shown to improve outcomes 1
• 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
• Individuals with uncomplicated DKA may be treated with subcutaneous rapid-acting insulin analogs in the emergency department or step-down units, with adequate fluid replacement, frequent POC blood glucose monitoring, and treatment of any concurrent infections 1

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Assessment of Diabetic Ketoacidosis (DKA)

• The assessment of DKA involves confirming the diagnosis through the presence of three criteria: 'D' (elevated blood glucose levels or a family history of diabetes mellitus), 'K' (presence of high urinary or blood ketoacids), and 'A' (high anion gap metabolic acidosis) 2.
• Measurement of urinary glucose and ketones, arterial blood pH and blood gases, and serum ketones can establish the diagnosis rapidly 3.
• Serum potassium levels should be obtained before giving insulin, as insulin therapy can decrease serum potassium levels and potentially precipitate a fatal cardiac arrhythmia in a patient with hypokalemia 4.

Plan for Diabetic Ketoacidosis (DKA)

• The mainstays of treatment include:
  • Restoration of circulating volume
  • Insulin therapy
  • Electrolyte replacement
  • Treatment of any underlying precipitating event 2
• Rapid infusion of large volumes of fluids and electrolytes, together with continuous infusion of low doses of insulin, provides effective restoration of fluid and electrolyte balance and correction of metabolic derangements 3.
• In severe DKA, protocols should advise that the insulin infusion be continued at high dose (4 to 6 U/h or more), with appropriate glucose infusion to prevent hypoglycaemia, until the serum bicarbonate is normal or nearly so 5.
• Sodium bicarbonate infusion may be necessary in special circumstances, such as very severe acidosis, but its use is controversial and additional studies are needed to determine its utility 6.