Management of Diabetic Ketoacidosis (DKA)
Diabetic ketoacidosis requires immediate treatment with intravenous fluids, insulin, and electrolyte replacement, with individualized management based on clinical and laboratory assessment to restore circulatory volume, resolve hyperglycemia and ketosis, and correct electrolyte imbalances. 1
Diagnosis of DKA
DKA is diagnosed when the following criteria are present:
- Blood glucose >250 mg/dL (though euglycemic DKA can occur)
- Arterial pH <7.3 or serum bicarbonate <15 mEq/L
- Presence of ketones in blood or urine
Initial Assessment
- Laboratory evaluation: plasma glucose, blood urea nitrogen/creatinine, serum ketones, electrolytes (with calculated anion gap), osmolality, arterial blood gases, complete blood count, urinalysis 1
- Identify precipitating factors: infection, myocardial infarction, stroke, medication non-adherence 1
Treatment Algorithm
1. Fluid Replacement
- Initial fluid therapy: 0.9% NaCl at 15-20 mL/kg/hr (1-1.5 L in first hour for adults) in absence of cardiac compromise 1
- Subsequent fluid choice:
- 0.45% NaCl at 4-14 mL/kg/hr if corrected serum sodium is normal/elevated
- 0.9% NaCl at similar rate if corrected serum sodium is low 1
2. Insulin Therapy
- For critically ill or mentally obtunded patients: Continuous intravenous insulin is standard of care 1
- For uncomplicated DKA: Subcutaneous rapid-acting insulin analogs may be used in emergency department or step-down units 1
- This approach can be safer and more cost-effective than IV insulin
- Must ensure adequate fluid replacement and frequent blood glucose monitoring
3. Electrolyte Replacement
- Potassium: Add 20-30 mEq/L potassium (2/3 KCl and 1/3 KPO₄) to IV fluids once renal function is assured 1
- Monitor electrolytes frequently and adjust replacement accordingly
4. Transitioning from IV to Subcutaneous Insulin
- Administer basal insulin 2-4 hours before stopping IV insulin to prevent recurrence of ketoacidosis and rebound hyperglycemia 1
- Recent studies show that administering a low dose of basal insulin analog alongside IV insulin may prevent rebound hyperglycemia without increased hypoglycemia risk 1
5. Bicarbonate Administration
- Generally not recommended as studies show no difference in resolution of acidosis or time to discharge 1
Special Considerations
Children and Adolescents with DKA
- Insulin therapy must be initiated for children and adolescents who are ketotic or in DKA 1
- Treatment should be supervised by a physician experienced in treating this complication 1
Monitoring During Treatment
- Frequent monitoring of vital signs, neurological status, and laboratory parameters
- Blood glucose monitoring every 2-4 hours while patient is NPO 1
- Monitor for complications, especially cerebral edema in children
Discharge Planning
A structured discharge plan should be developed, including:
- Information on medication changes and follow-up needs 1
- Transmission of discharge summaries to primary care provider promptly 1
- Scheduling follow-up appointments prior to discharge 1
- Education on sick-day management to prevent recurrent DKA 1
Potential Complications to Monitor
Hypoglycemia
- Can occur during insulin treatment
- Symptoms range from mild (sweating, anxiety, tremor) to severe (disorientation, seizures, unconsciousness) 2
- Monitor blood glucose frequently to avoid
Cerebral Edema
- More common in children
- Presents with headache, altered mental status, seizures, or coma
- Requires immediate intervention
Electrolyte Abnormalities
- Hypokalemia: Can develop during treatment as insulin drives potassium into cells
- Hyperchloremic metabolic acidosis: Can occur with excessive normal saline administration
Prevention of Recurrent DKA
- Patient education on sick-day management
- Ensuring access to insulin and supplies
- Regular follow-up with healthcare providers
- Identification and management of precipitating factors
By following this structured approach to DKA management, focusing on fluid resuscitation, insulin therapy, and electrolyte replacement while addressing the underlying cause, clinicians can effectively treat this serious complication of diabetes and reduce associated morbidity and mortality.