What is the treatment protocol for diabetic ketoacidosis (DKA)?

Diabetic Ketoacidosis (DKA) Treatment Protocol

The treatment of DKA requires immediate administration of intravenous fluids, insulin therapy, electrolyte replacement, and identification of precipitating factors, with frequent monitoring of clinical and laboratory parameters until resolution. 1

Diagnostic Criteria for DKA

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

Initial Assessment

• Obtain arterial blood gases, complete blood count, urinalysis, blood glucose, BUN, electrolytes, chemistry profile, and creatinine
• ECG and chest X-ray as needed
• Cultures (blood, urine, throat) if infection is suspected
• Calculate anion gap and corrected sodium

Treatment Algorithm

1. Fluid Therapy (Adult Patients)

• First hour: Isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour (typically 1-1.5 L)
• Subsequent hours:
  • If corrected sodium normal/high: 0.45% NaCl at 4-14 mL/kg/hour
  • If corrected sodium low: 0.9% NaCl at 4-14 mL/kg/hour
• Add dextrose (5-10%) when blood glucose reaches 250 mg/dL
• Target correction of estimated deficits within 24 hours
• Monitor fluid input/output and hemodynamic status

2. Insulin Therapy

• Initial: Regular insulin IV continuous infusion at 0.1 units/kg/hour (typically 5-7 units/hour)
• Adjustment:
  • If glucose doesn't fall by 50 mg/dL in first hour, double insulin infusion rate
  • When glucose reaches 250 mg/dL, reduce to 0.05-0.1 units/kg/hour
• Transition to subcutaneous: When DKA resolves (glucose <200 mg/dL, bicarbonate ≥18 mEq/L, venous pH >7.3)
  • Continue IV insulin for 1-2 hours after starting subcutaneous insulin
  • For NPO patients: supplement with subcutaneous regular insulin as needed

3. Potassium Replacement

• Add 20-30 mEq/L potassium to IV fluids once renal function is confirmed and serum K+ <5.3 mEq/L
• Use 2/3 KCl and 1/3 KPO₄
• Critical point: Insulin therapy lowers serum potassium, so monitor closely and maintain supplementation

4. Bicarbonate Therapy

• Generally not necessary if pH >7.0
• For pH 6.9-7.0: Consider 50 mmol sodium bicarbonate in 200 mL sterile water over 1 hour
• For pH <6.9: Bicarbonate may be beneficial

5. Phosphate Replacement

• Routine replacement not shown to improve outcomes
• Consider careful replacement only for patients with:
  • Cardiac dysfunction
  • Anemia
  • Respiratory depression
  • Serum phosphate <1.0 mg/dL

Monitoring During Treatment

• Blood glucose: Every 1-2 hours
• Electrolytes, BUN, creatinine: Every 2-4 hours
• Venous pH and anion gap: Every 4-6 hours until acidosis resolves
• Monitor for signs of cerebral edema, especially in pediatric patients

Special Considerations for Pediatric Patients

• Initial fluid: 0.9% NaCl at 10-20 mL/kg/hour for first hour
• Do not exceed 50 mL/kg in first 4 hours
• Fluid replacement should be more gradual (over 48 hours)
• Higher risk for cerebral edema - avoid rapid osmolality changes

Criteria for Resolution of DKA

• Blood glucose <200 mg/dL
• Serum bicarbonate ≥18 mEq/L
• Venous pH >7.3

Common Pitfalls to Avoid

1. Inadequate potassium replacement: Even with normal initial K+ levels, total body potassium is depleted
2. Rapid correction of glucose: Can lead to cerebral edema, especially in children
3. Premature discontinuation of insulin: Continue until ketoacidosis resolves, not just until glucose normalizes
4. Failure to identify precipitating factors: Look for infection, medication non-compliance, or new-onset diabetes
5. Using nitroprusside method alone to monitor ketone clearance: This method doesn't measure β-hydroxybutyrate, the predominant ketoacid in DKA

Transition to Subcutaneous Insulin

When DKA resolves, transition to a multiple-dose schedule using a combination of short/rapid-acting and intermediate/long-acting insulin. Continue IV insulin for 1-2 hours after starting subcutaneous insulin to prevent rebound hyperglycemia.

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