What is the treatment for Diabetic Ketoacidosis (DKA)?

Treatment of Diabetic Ketoacidosis (DKA)

The management of DKA requires immediate fluid resuscitation, insulin therapy, electrolyte replacement, and identification of underlying causes, with continuous intravenous insulin being the standard of care for moderate to severe cases. 1

Initial Assessment and Diagnosis

• Diagnostic criteria for DKA: 1

  • Blood glucose >250 mg/dL
  • Venous pH <7.3
  • Serum bicarbonate <15 mEq/L
  • Moderate ketonuria or ketonemia

• Initial laboratory evaluation: 1

  • Blood glucose, venous blood gases
  • Electrolytes, BUN, creatinine
  • Calcium, phosphorous
  • Urinalysis
  • Consider: cultures, chest X-ray if infection suspected

Treatment Algorithm

1. Fluid Replacement

• Initial fluid therapy: 1

  • Adults: 1-1.5 L of 0.9% NaCl (normal saline) in first hour
  • Pediatric patients: 10-20 mL/kg/h of isotonic saline (0.9% NaCl), not exceeding 50 mL/kg in first 4 hours

• Subsequent fluid therapy:

  • After initial resuscitation, continue with 0.45-0.9% saline at 4-14 mL/kg/h
  • When glucose reaches 250 mg/dL, add dextrose (5-10%) to IV fluids
  • Goal: Replace estimated deficit over 24-48 hours

2. Insulin Therapy

• For moderate to severe DKA: 1

  • Continuous IV insulin is the standard of care
  • Initial dose: 0.1 units/kg/hour (no bolus recommended)
  • If glucose doesn't fall by 50 mg/dL in first hour, double insulin infusion rate hourly until steady glucose decline of 50-75 mg/dL/hour is achieved
  • When glucose reaches 250 mg/dL, reduce insulin to 0.05-0.1 units/kg/hour and add dextrose to IV fluids

• For mild DKA: 1

  • Subcutaneous or intramuscular insulin may be used
  • Initial "priming" dose of 0.4-0.6 units/kg (half IV bolus, half SC/IM)
  • Then 0.1 units/kg/hour subcutaneously or intramuscularly

3. Electrolyte Replacement

• Potassium: 1

  • If initial K+ <3.3 mEq/L: Hold insulin and give potassium until K+ >3.3 mEq/L
  • If initial K+ 3.3-5.3 mEq/L: Add 20-30 mEq potassium to each liter of IV fluid
  • If initial K+ >5.3 mEq/L: Withhold potassium, check levels frequently
  • Composition: 2/3 KCl or K-acetate and 1/3 KPO₄

• Bicarbonate: 1

  • Generally not recommended for most patients
  • Consider only if pH <6.9 (50 mmol sodium bicarbonate in 200 mL sterile water over 1 hour)
  • Not recommended for pediatric patients except in severe cases with hemodynamic instability

4. Monitoring

• Laboratory monitoring: 1

  • Check electrolytes, glucose, BUN, creatinine every 2-4 hours
  • Monitor venous pH and anion gap to track resolution of acidosis
  • β-hydroxybutyrate (β-OHB) in blood is preferred method for monitoring ketosis

• Clinical monitoring:

  • Vital signs, mental status, fluid input/output
  • Watch for signs of cerebral edema, especially in pediatric patients

Criteria for Resolution of DKA

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

Transition to Subcutaneous Insulin

• Administer basal insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia 1
• When patient can eat, start multiple-dose insulin regimen with basal and bolus components
• Continue IV insulin for 1-2 hours after subcutaneous insulin is initiated

Important Considerations and Pitfalls

1. Cerebral edema prevention: 2, 3

   • Most common cause of mortality in pediatric DKA
   • Avoid rapid correction of glucose and osmolality
   • Avoid excessive fluid administration
   • Gradual rehydration over 24-48 hours

2. Monitoring ketones: 1

   • Nitroprusside method only measures acetoacetic acid and acetone, not β-OHB
   • During treatment, β-OHB converts to acetoacetic acid, which may falsely suggest worsening ketosis
   • Direct measurement of β-OHB is preferred when available

3. Identifying and treating underlying causes: 1, 4

   • Common precipitants: infection, new diagnosis of diabetes, insulin non-adherence
   • Consider SGLT2 inhibitor use as potential cause of euglycemic DKA

4. Special considerations for euglycemic DKA: 4

   • Can occur with SGLT2 inhibitor use
   • Same treatment approach but with earlier addition of dextrose

By following this structured approach to DKA management with appropriate fluid resuscitation, insulin therapy, and electrolyte replacement, while carefully monitoring for complications, mortality from DKA can be significantly reduced.