What is the workup and management for Diabetic Ketoacidosis (DKA)?

Workup and Management of Diabetic Ketoacidosis (DKA)

The management of DKA requires immediate laboratory assessment, aggressive fluid resuscitation, insulin therapy, electrolyte replacement, and identification of precipitating factors to reduce mortality and prevent complications. 1

Diagnostic Workup

Initial Laboratory Assessment (STAT)

• Blood glucose (hyperglycemia typically >250 mg/dL, though euglycemic DKA can occur)
• Venous blood gases (pH <7.3)
• Serum electrolytes (sodium, potassium, chloride, bicarbonate <18 mEq/L)
• Blood urea nitrogen and creatinine
• Calcium and phosphorous
• Complete urinalysis (check for ketones)
• Anion gap calculation (typically >10 mEq/L)
• Beta-hydroxybutyrate (β-OHB) measurement (preferred over urine ketones) 1

Additional Testing Based on Clinical Presentation

• Complete blood count with differential
• A1C
• Electrocardiogram (especially important for monitoring potassium-related changes)
• Blood and urine cultures (if infection suspected)
• Chest radiography (if respiratory symptoms present)
• Consider: amylase, lipase, hepatic transaminases, troponin, creatine kinase 2

Management Protocol

1. Fluid Replacement

• Initial fluid: 0.9% sodium chloride at 15-20 mL/kg/hr for the first hour (typically 1-1.5 L in adults)
• Subsequent fluid: Continue 0.9% sodium chloride at 4-14 mL/kg/hr based on hemodynamic status
• Switch to 0.45% saline when serum sodium is normal or elevated
• Total body water deficit is typically 5-10% 1

2. Insulin Therapy

• For moderate to severe DKA: Continuous IV insulin infusion is the standard of care

  • Initial dose: 0.1 units/kg/hr without bolus (avoid bolus to reduce cerebral edema risk) 3
  • Continue until resolution of ketoacidosis (pH >7.3, bicarbonate >18 mEq/L)
  • If glucose falls below 200 mg/dL before ketoacidosis resolves, add dextrose to IV fluids and continue insulin

• For mild DKA: Subcutaneous rapid-acting insulin may be considered

  • Initial "priming" dose: 0.4-0.6 units/kg (half IV bolus, half SC/IM)
  • Followed by 0.1 unit/kg SC/IM hourly 1

3. Potassium Replacement

• Begin potassium replacement when serum K+ <5.2 mEq/L and adequate urine output is established
• If initial K+ <3.3 mEq/L, hold insulin until K+ >3.3 mEq/L to prevent arrhythmias
• Add 20-30 mEq potassium (⅔ as KCl, ⅓ as KPO₄) to each liter of IV fluid 1
• Monitor potassium levels every 2-4 hours

4. Bicarbonate Therapy

• Generally not recommended in adult or pediatric patients
• Consider only if pH <6.9 or in cases of hemodynamic instability with severe acidosis 1

5. Monitoring During Treatment

• Blood glucose: Every 1-2 hours
• Electrolytes, BUN, creatinine: Every 2-4 hours
• Venous pH and anion gap: Every 2-4 hours until resolution
• Continuous cardiac monitoring if severe electrolyte abnormalities
• Neurological checks every 1-2 hours (especially in children) 1

Transition from IV to SC Insulin

1. Begin subcutaneous basal insulin 2-4 hours before discontinuing IV insulin
2. Continue IV insulin for 1-2 hours after first SC dose to prevent rebound hyperglycemia
3. When patient can eat, initiate basal-bolus insulin regimen 1

Resolution Criteria for DKA

• Blood glucose <200 mg/dL
• Serum bicarbonate ≥18 mEq/L
• Venous pH >7.3
• Anion gap normalized 1

Complications to Monitor and Prevent

Cerebral Edema (Highest Mortality Risk)

• More common in children and young adults
• Prevention strategies:
  • Avoid excessive fluid administration (no more than 2x maintenance requirements)
  • Avoid rapid decreases in plasma osmolality
  • Gradual correction of hyperglycemia
  • Avoid insulin boluses 3

Other Complications

• Hypoglycemia: Monitor glucose frequently, add dextrose when glucose <200 mg/dL
• Hypokalemia: Begin K+ replacement early, monitor ECG
• Hypophosphatemia: Consider replacement if <1.0 mg/dL or if cardiac/respiratory dysfunction
• Thromboembolism: Consider prophylaxis in high-risk patients 4

Discharge Planning

• Structured discharge plan tailored to the individual patient
• Identify and address precipitating factors (infection, medication non-adherence, etc.)
• Patient education on sick-day management and ketone testing
• Follow-up appointment within 1-2 weeks
• Clear insulin regimen with appropriate dosing 1

By following this structured approach to DKA management with close monitoring and appropriate interventions, mortality and complication rates can be significantly reduced.