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

• Fluid resuscitation: Begin with aggressive intravenous fluid resuscitation using 0.9% normal saline at 15-20 mL/kg/hr for the first hour (typically 1-1.5 L in adults), then adjust to 250-500 mL/hr based on hemodynamic status, as recommended by recent guidelines 1.
• Insulin therapy: Start continuous intravenous insulin at 0.1 units/kg/hr after the initial fluid bolus, with recent studies suggesting that 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.
• Electrolyte replacement: Replace potassium when levels are below 5.2 mEq/L and urine output is adequate, typically at 20-30 mEq per liter of IV fluid, and address phosphate and magnesium deficiencies as needed, as recommended by recent guidelines 1.
• Identifying the underlying trigger: Investigate and treat the precipitating cause, commonly infection, medication non-adherence, or new-onset diabetes, as recommended by recent guidelines 1. It is essential to monitor electrolytes, glucose, and arterial blood gases every 2-4 hours initially and to adjust the treatment plan accordingly, with recent guidelines emphasizing the importance of individualization of treatment based on a careful clinical and laboratory assessment 1. Bicarbonate therapy is rarely indicated except in severe acidosis (pH < 6.9), as recent studies have shown that its use makes no difference in the resolution of acidosis or time to discharge 1. The goal of treatment is to restore circulatory volume and tissue perfusion, resolve hyperglycemia and ketoacidosis, and correct electrolyte imbalance and acidosis, with recent guidelines providing a comprehensive approach to the management of DKA 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 initial management of Diabetic Ketoacidosis (DKA) involves obtaining medical assistance immediately. Key steps include:

• Monitoring blood glucose and ketone levels
• Administering insulin and fluids to correct hyperglycemia and dehydration
• Identifying and treating any underlying causes of DKA, such as infection or omission of insulin doses 2 It is crucial to recognize the symptoms of DKA, including drowsy feeling, flushed face, thirst, loss of appetite, and fruity odor on the breath, and to seek medical help promptly to prevent severe complications or death 2.

From the Research

Initial Management of Diabetic Ketoacidosis (DKA)

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

• Fluid replacement to correct dehydration and electrolyte imbalances
• Insulin therapy to lower blood glucose levels
• Monitoring of serum glucose, electrolytes, and acid-base status

Fluid Replacement

Fluid replacement is a critical component of DKA management, with the goal of correcting dehydration and electrolyte imbalances. Studies have shown that:

• Isotonic saline can be used as an initial fluid replacement, followed by 5% glucose in 0.45% saline with potassium chloride and/or potassium phosphate to replace intracellular fluids 3
• Balanced Electrolyte Solutions (BES) may be a more physiological alternative to 0.9% saline, and have been shown to result in faster resolution of DKA 4
• Low chloride solutions may also be effective in correcting acidosis and resolving DKA 5

Insulin Therapy

Insulin therapy is essential for lowering blood glucose levels in DKA patients. Studies have shown that:

• Low-dose intravenous insulin can be effective in treating DKA, with a starting dose of 6 U/h and adjustment as needed 3
• In severe DKA, higher doses of insulin (4-6 U/h or more) may be necessary to achieve normalization of serum bicarbonate levels 6

Monitoring and Adjunctive Therapy

Monitoring of serum glucose, electrolytes, and acid-base status is crucial in DKA management. Adjunctive therapy, such as potassium replacement and bicarbonate administration, may also be necessary in some cases. Studies have shown that:

• Regular monitoring of serum glucose and electrolytes can help guide therapy and prevent complications 3
• Potassium replacement is essential to prevent hypokalemia, particularly in patients receiving insulin therapy 3
• Bicarbonate administration may be necessary in cases of severe acidosis, but its use should be guided by careful monitoring of acid-base status 6