What is the standard protocol for managing diabetic ketoacidosis (DKA)?

Standard Protocol for Managing Diabetic Ketoacidosis (DKA)

The standard protocol for managing DKA requires aggressive fluid resuscitation, insulin therapy, electrolyte replacement, identification of precipitating factors, and frequent monitoring to reduce morbidity and mortality. 1

Diagnostic Criteria for DKA

DKA is diagnosed when all three criteria are present:

• Blood glucose >250 mg/dL
• Arterial pH <7.3 and serum bicarbonate <15 mEq/L
• Moderate ketonuria or ketonemia 1

DKA severity can be classified as:

• Mild: pH 7.25-7.30, bicarbonate 15-18 mEq/L
• Moderate: pH 7.00-7.24, bicarbonate 10-15 mEq/L
• Severe: pH <7.00, bicarbonate <10 mEq/L 1

Initial Assessment

1. Laboratory evaluation (STAT):

   • Arterial blood gases
   • Complete blood count with differential
   • Urinalysis
   • Blood glucose
   • Blood urea nitrogen (BUN)
   • Electrolytes
   • Chemistry profile
   • Creatinine levels
   • ECG
   • Chest X-ray and cultures as needed 1

2. Identify precipitating factors:

   • Infection (most common)
   • New-onset diabetes
   • Insulin non-adherence
   • Myocardial infarction
   • Stroke
   • Medications (e.g., SGLT2 inhibitors) 2

Treatment Protocol

1. Fluid Therapy

• First hour (adults): Isotonic saline (0.9% NaCl) at 15-20 mL/kg/hr (approximately 1-1.5 L in average adult) 1
• Subsequent fluid choice:
  • If corrected serum sodium is normal or elevated: 0.45% NaCl at 4-14 mL/kg/hr
  • If corrected serum sodium is low: 0.9% NaCl at similar rate
  • Add potassium (20-30 mEq/L) once renal function is assured 1
• Pediatric patients: Initial fluid with isotonic saline at 10-20 mL/kg/hr, not exceeding 50 mL/kg in first 4 hours 1

2. Insulin Therapy

• Standard approach: Continuous intravenous regular insulin at 0.1 units/kg/hr until ketoacidosis resolves 1, 3
• For mild DKA: Consider "priming" dose of regular insulin (0.4-0.6 units/kg), half as IV bolus and half as subcutaneous/intramuscular injection, followed by 0.1 unit/hr subcutaneously/intramuscularly 1
• Continue insulin until resolution of DKA (glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, and venous pH ≥7.3) 1

3. Electrolyte Management

• Potassium: Add 20-30 mEq/L of potassium (2/3 KCl and 1/3 KPO4) to IV fluids once renal function is confirmed and if serum potassium is <5.3 mEq/L 1
• Bicarbonate: Generally not recommended. Consider only if pH <6.9, and then administer cautiously 1, 4
• Phosphate: Routine replacement not necessary but consider in patients with cardiac dysfunction, anemia, respiratory depression, or serum phosphate <1.0 mg/dL 1

4. Monitoring

• Blood glucose: Every 1-2 hours
• Electrolytes, BUN, creatinine: Every 2-4 hours
• Venous pH and anion gap: Every 2-4 hours until DKA resolves
• β-hydroxybutyrate (β-OHB): Preferred method for monitoring ketosis (if available) 1

Transition to Subcutaneous Insulin

1. When to transition: After resolution of DKA (glucose <200 mg/dL, bicarbonate ≥18 mEq/L, pH ≥7.3)
2. How to transition:
   • Administer basal insulin 2-4 hours before stopping IV insulin
   • If patient can eat, start multiple-dose insulin regimen with basal and bolus insulin
   • Continue IV insulin for 1-2 hours after subcutaneous insulin is started 1
   • If NPO, continue IV insulin and supplement with subcutaneous regular insulin as needed 1

Special Considerations

• Cerebral edema: More common in children and adolescents; avoid rapid fluid administration and monitor neurological status closely 3
• Bicarbonate therapy: Studies show no benefit in resolution of acidosis or time to discharge; generally not recommended 1
• Mild DKA: May be treated with subcutaneous insulin in emergency department or step-down units rather than ICU 1

Discharge Planning

• Provide education on DKA recognition, prevention, and management
• Ensure appropriate insulin regimen and dosing
• Address precipitating factors and prevent recurrence
• Arrange appropriate follow-up 1

Pitfalls to Avoid

1. Failure to identify and treat the underlying precipitating cause
2. Overly rapid correction of fluid deficits, especially in pediatric patients
3. Premature discontinuation of IV insulin before resolution of ketoacidosis
4. Inadequate potassium replacement
5. Abrupt transition from IV to subcutaneous insulin without overlap
6. Unnecessary use of bicarbonate therapy
7. Relying on nitroprusside method to monitor ketones (measures acetoacetic acid and acetone but not β-OHB) 1