What is the initial treatment for a patient presenting with Diabetic Ketoacidosis (DKA)?

From the Guidelines

The initial treatment for a patient presenting with Diabetic Ketoacidosis (DKA) should focus on aggressive fluid resuscitation, insulin therapy, and electrolyte management, as outlined in 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.

• Begin with intravenous fluid resuscitation using isotonic saline (0.9% NaCl) at 15-20 mL/kg/hr for the first hour (typically 1-2 L in adults), then adjust to 250-500 mL/hr based on hemodynamic status.
• After starting fluids, administer regular insulin as an IV bolus of 0.1 units/kg followed by a continuous infusion at 0.1 units/kg/hr.
• Potassium replacement should begin if serum potassium is below 5.3 mEq/L, typically with 20-30 mEq of potassium chloride per liter of IV fluid.
• Once blood glucose reaches 200-250 mg/dL, add dextrose (D5W or D10W) to the IV fluids while continuing insulin to clear ketones.
• Bicarbonate therapy is generally not recommended unless pH is below 6.9, as several studies have shown that its use made no difference in resolution of acidosis or time to discharge 1. Throughout treatment, monitor glucose hourly, electrolytes every 2-4 hours, and assess for resolution of acidosis. This aggressive approach addresses the fundamental issues in DKA: dehydration from osmotic diuresis, insulin deficiency leading to hyperglycemia and ketogenesis, and electrolyte imbalances that can cause life-threatening complications. In critically ill and mentally obtunded individuals with DKA or hyperosmolar hyperglycemia, continuous intravenous insulin is the standard of care, while patients with uncomplicated DKA may sometimes be treated with subcutaneous rapid-acting insulin analogs in the emergency department or step-down units 1.

From the Research

Initial Treatment for Diabetic Ketoacidosis (DKA)

The initial treatment for a patient presenting with DKA involves several key components:

• Restoration of circulating volume and electrolyte replacement 2
• Correction of insulin deficiency to resolve metabolic acidosis and ketosis 2, 3
• Reduction of the risk of cerebral edema 2, 3
• Avoidance of other complications of therapy, such as hypoglycemia, hypokalemia, hyperkalemia, and hyperchloremic acidosis 2, 3
• Identification and treatment of precipitating events 2

Fluid Replacement and Insulin Therapy

• Isotonic normal saline is the standard for initial fluid resuscitation, although balanced solutions may lead to faster DKA resolution 3
• Continuous IV insulin is recommended after fluid status has been restored and potassium levels have been achieved 3
• Subcutaneous insulin can be started only after the resolution of metabolic acidosis 2, 3

Electrolyte Replacement and Monitoring

• Regular monitoring of electrolyte levels, including potassium, phosphate, and magnesium, is essential for DKA management 3, 4
• Hypokalemia can worsen despite IV repletion, and severe hypokalemia may necessitate delaying insulin therapy 4

Special Considerations

• In patients with insulin allergy, continuous IV recombinant human insulin infusion may be an option for treating severe DKA 5
• Euglycaemic DKA in patients prescribed sodium-glucose cotransporter inhibitors requires recognition and management 6
• DKA management in special populations, such as those with chronic kidney disease or pregnancy, may differ from standard treatment and requires careful consideration 6