What is the management of diabetic ketoacidosis?

Management of Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) requires immediate treatment with intravenous insulin and aggressive fluid replacement to correct metabolic derangements and prevent mortality. 1

Diagnostic Criteria

DKA is characterized by:

• Blood glucose >250 mg/dL
• Arterial pH <7.3
• Serum bicarbonate <15 mEq/L
• Presence of ketonemia or ketonuria 1

Initial Assessment

• Laboratory evaluation:

  • Plasma glucose, blood urea nitrogen/creatinine
  • Serum ketones, electrolytes with calculated anion gap
  • Arterial blood gases
  • Complete blood count with differential
  • Urinalysis and urine ketones
  • ECG 1

• Identify precipitating factors:

  • Infection (obtain cultures of urine, blood, throat)
  • Myocardial infarction
  • Stroke
  • Medication non-adherence 1

Treatment Algorithm

1. Fluid Replacement

• Initial: Isotonic saline (0.9% NaCl) at 15-20 mL/kg/hr (1-1.5 L in average adult) during first hour 1
• Subsequent fluid choice:
  • If corrected serum sodium normal/elevated: 0.45% NaCl at 4-14 mL/kg/hr
  • If corrected serum sodium low: 0.9% NaCl at similar rate 1
• Goal: Correct estimated fluid deficits within 24 hours 1

2. Insulin Therapy

• In critically ill or mentally obtunded patients: Continuous intravenous insulin is standard of care 1
• Initial IV insulin: Regular insulin 0.1 units/kg/hr 2
• Continue until resolution of ketoacidosis (pH >7.3, bicarbonate >15 mEq/L) 1
• For mild/moderate uncomplicated DKA: Subcutaneous rapid-acting insulin analogs may be used in emergency department or step-down units 1

3. Electrolyte Management

• Potassium:
  • Once renal function is assured, add 20-30 mEq/L potassium (2/3 KCl and 1/3 KPO₄) to IV fluids 1
  • Monitor levels closely to avoid hypo/hyperkalemia

4. Transition to Subcutaneous Insulin

• Administer basal insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia 1
• Recent evidence: Low-dose basal insulin analog given with IV insulin may prevent rebound hyperglycemia without increased hypoglycemia risk 1

5. Bicarbonate Therapy

• Generally not recommended
• Multiple studies show no difference in resolution of acidosis or time to discharge 1
• Only consider in extreme acidosis or specific clinical scenarios 3

Special Considerations

Pediatric Patients

• In youth with ketosis/ketoacidosis:
  • Initiate subcutaneous or IV insulin to rapidly correct hyperglycemia and metabolic derangement
  • Once acidosis resolves, start metformin while continuing subcutaneous insulin 1
  • Test for pancreatic autoantibodies to differentiate between type 1 and type 2 diabetes 1

Monitoring During Treatment

• Vital signs and neurological status
• Fluid input/output
• Blood glucose every 1-2 hours
• Electrolytes, blood gases, and pH every 2-4 hours until stable 1

Discharge Planning

• Structured discharge plan tailored to individual patient 1
• Begin discharge planning at admission
• Schedule follow-up appointment with primary care provider or endocrinologist within 1 month (or 1-2 weeks if medications changed) 1
• Patient education on insulin adjustment during illness and monitoring of glucose/ketone levels 4

Common Pitfalls to Avoid

1. Failing to recognize DKA in patients with only mildly elevated glucose
2. Inadequate fluid resuscitation
3. Discontinuing insulin before resolution of ketosis (even if glucose normalizes)
4. Not monitoring potassium closely during treatment
5. Failing to identify and treat the precipitating cause 5
6. Transitioning from IV to subcutaneous insulin without overlap, risking rebound hyperglycemia 1

By following this structured approach to DKA management, clinicians can effectively treat this potentially life-threatening condition while minimizing complications.