From the Guidelines
The initial management of Diabetic Ketoacidosis (DKA) should prioritize fluid resuscitation, insulin therapy, electrolyte replacement, and identifying/treating the underlying trigger, with the goal of restoring circulatory volume, resolving ketoacidosis, and correcting electrolyte imbalances and acidosis, as outlined in the most recent guidelines 1. The management of DKA involves several key components, including:
- Aggressive fluid resuscitation to restore circulatory volume and tissue perfusion
- Insulin therapy to resolve ketoacidosis and correct hyperglycemia
- Electrolyte replacement to correct imbalances and acidosis
- Identification and treatment of the underlying trigger, such as sepsis, myocardial infarction, or stroke According to the most recent guidelines 1, continuous intravenous insulin is the standard of care for critically ill and mentally obtunded individuals with DKA, while subcutaneous rapid-acting insulin analogs may be used for individuals with uncomplicated DKA. The use of bicarbonate therapy is generally not recommended unless the pH is below 6.9, as several studies have shown that it makes no difference in the resolution of acidosis or time to discharge 1. Key considerations in the management of DKA include:
- Providing adequate fluid replacement and frequent monitoring of electrolytes, glucose, and arterial pH
- Administering basal insulin 2-4 hours before stopping intravenous insulin to prevent recurrence of ketoacidosis and rebound hyperglycemia
- Using a low dose of basal insulin analog in addition to intravenous insulin infusion to prevent rebound hyperglycemia without increased risk of hypoglycemia 1
From the FDA Drug Label
The intravenous administration of Humulin R U-100 was tested in 21 patients with type 1 diabetes The patients' usual doses of insulin were temporarily held, and blood glucose concentrations were maintained at a range of 200 – 260 mg/dL for one to three hours during a run-in phase of intravenous Humulin R U-100 followed by a 6-hour assessment phase. During the assessment phase patients received intravenous Humulin R at an initial dose of 0. 5 U/h, adjusted to maintain blood glucose concentrations near normoglycemia (100 to 160 mg/dL). During the study, 4 patients experienced diabetic ketoacidosis.
The initial management for Diabetic Ketoacidosis (DKA) involves intravenous administration of insulin, with an initial dose of 0.5 U/h, adjusted to maintain blood glucose concentrations near normoglycemia (100 to 160 mg/dL) 2.
- The goal is to achieve near normoglycemia, with blood glucose levels within the target range of 100 to 160 mg/dL.
- Intravenous insulin is used to manage DKA, with adjustments made as needed to maintain target blood glucose levels.
From the Research
Initial Management of Diabetic Ketoacidosis (DKA)
The initial management of DKA involves several key steps:
- Restoration of circulating volume and electrolyte replacement 3
- Correction of insulin deficiency to resolve metabolic acidosis and ketosis 3
- Reduction of the risk of cerebral edema 3
- Avoidance of other complications of therapy, such as hypoglycemia, hypokalemia, hyperkalemia, and hyperchloremic acidosis 3
- Identification and treatment of precipitating events 3, 4
Treatment Protocols
Different treatment protocols have been proposed, including:
- The use of low-dose intravenous insulin and isotonic saline to replace extracellular fluids, followed by glucose and potassium chloride or phosphate to replace intracellular fluids 5
- An alternative protocol that abbreviates the time on intravenous infusion lines, using oral fluids and potassium replacement, and subcutaneous rapid-acting insulin analog 3
- A two-bag intravenous fluid system that has been shown to decrease the duration of intravenous insulin therapy 6
Monitoring and Adjustments
Close monitoring of the patient's clinical and laboratory findings is crucial, including: