What are the next steps for a patient with diabetic ketoacidosis (DKA) and a blood glucose level (BGL) of 10 mmol/L and ketone level of 7.0 mmol/L?

From the Guidelines

For a patient with diabetic ketoacidosis (DKA) with a blood glucose level of 10 mmol/L and ketone level of 7.0 mmol/L, continue intravenous insulin therapy despite the relatively normal glucose level, as the high ketone level indicates ongoing metabolic derangement requiring insulin to suppress ketogenesis, as recommended by the most recent guidelines 1. The management goals include restoration of circulatory volume and tissue perfusion, resolution of ketoacidosis, and correction of electrolyte imbalance and acidosis. Key steps in management include:

• Administering regular insulin at 0.1 units/kg/hour while adding dextrose to the IV fluids (typically D10W) to prevent hypoglycemia while continuing insulin therapy.
• Continuing fluid resuscitation with isotonic fluids (normal saline) at a maintenance rate if the patient is hemodynamically stable, and replacing electrolytes, particularly potassium, as needed based on serum levels.
• Monitoring blood glucose hourly, ketones every 2-4 hours, and electrolytes every 2-4 hours. The insulin infusion should continue until ketoacidosis resolves (ketones <1.0 mmol/L, anion gap normalizes, and pH >7.3), even if blood glucose normalizes earlier, as resolution of ketoacidosis often lags behind glucose normalization 1. Only transition to subcutaneous insulin after ketoacidosis resolves, with an overlap period of 1-2 hours between IV and subcutaneous insulin to prevent rebound ketosis, as supported by recent studies 1.

From the Research

Next Steps for Diabetic Ketoacidosis (DKA) Management

Given the patient's blood glucose level (BGL) of 10 mmol/L and ketone level of 7.0 mmol/L, the following steps can be considered:

• Restoration of circulating volume and electrolyte replacement, as emphasized in 2
• Correction of insulin deficiency to resolve metabolic acidosis and ketosis, with options including intravenous insulin or subcutaneous rapid-acting insulin analog 2, 3
• Monitoring of vital and neurological signs, as well as the patient's clinical and biochemical response to treatment, which may involve regular measurements of serum glucose, potassium, and ketone levels 3, 4

Treatment Considerations

• The use of low-dose insulin has been shown to be non-inferior to standard dose insulin in resolving DKA, with a similar time to resolution 5
• Subcutaneous insulin may be associated with reduced ICU admissions and hospital readmissions in children 5
• The choice of intravenous fluid, such as normal saline or Plasmalyte, may not significantly impact the time to resolution of DKA, but balanced solutions may lead to earlier correction of pH 6
• Potassium replacement should be considered to avoid hypokalemia, with a target level above 10 mmol/L 5

Monitoring and Adjustments

• Regular evaluation of electrolytes, phosphate, blood urea nitrogen, creatinine, urinalysis, complete blood cell count with differential, and A1C can help identify causes and complications of DKA 4
• Close monitoring of the patient's response to treatment can inform adjustments to insulin dosage, fluid replacement, and electrolyte management 2, 3