Management of Diabetic Ketoacidosis (DKA)
The standard treatment of DKA requires aggressive intravenous hydration, continuous intravenous insulin, correction of electrolytes, and treatment of the underlying cause. 1
Diagnosis and Classification
DKA is diagnosed based on the following criteria:
- Blood glucose >250 mg/dL
- Arterial pH <7.3
- Serum bicarbonate <18 mEq/L
- Presence of ketones in blood or urine
- Anion gap >10-12 mEq/L 1, 2
DKA severity classification:
- 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 2
Initial Assessment and Monitoring
Initial laboratory evaluation should include:
- Plasma glucose
- Blood urea nitrogen/creatinine
- Serum ketones
- Electrolytes (with calculated anion gap)
- Osmolality
- Arterial blood gases
- Complete blood count with differential
- Urinalysis and urine ketones
- ECG 2
Obtain bacterial cultures (urine, blood, throat) if infection is suspected and initiate appropriate antibiotics.
Treatment Protocol
1. Fluid Therapy
- Initial fluid: 0.9% NaCl at 15-20 mL/kg/h (1-1.5 L in average adult) during first hour 2, 1
- Continue with 500-1000 mL/h until dehydration is corrected 1
- Subsequent fluid choice depends on hydration state, electrolytes, and urine output
2. Insulin Therapy
- Start with IV bolus of regular insulin 0.15 U/kg
- Follow with continuous infusion at 0.1 U/kg/h (typically 5-7 U/h in adults)
- Adjust based on blood glucose levels 1
- For mild DKA, subcutaneous rapid-acting insulin may be considered (initial dose 0.4-0.6 U/kg followed by 0.1 U/kg) 1
3. Electrolyte Replacement
- Potassium: Start replacement when serum K+ <5.5 mEq/L and adequate urine output is present
- Add 20-30 mEq potassium (2/3 KCl and 1/3 KPO₄) per liter of solution 1
- Phosphate: Consider replacement in patients with cardiac dysfunction, anemia, respiratory depression, or serum phosphate <1.0 mg/dL 1
- Bicarbonate: Generally not recommended unless pH <6.9 1, 2
4. Monitoring
- Blood glucose: Every 1-2 hours
- Electrolytes, BUN, creatinine: Every 2-4 hours
- Venous pH and bicarbonate: Every 4-6 hours
- Strict fluid balance monitoring 1
Transition from IV to Subcutaneous Insulin
- Administer basal insulin (0.2 units/kg) 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia 1, 2
- Continue IV insulin until metabolic acidosis resolves 2
- Initiate NPH insulin at 0.6-1 U/kg/day approximately 12 hours after treatment initiation 3
Discharge Criteria and Planning
Discharge criteria:
- Blood glucose <200 mg/dL
- Serum bicarbonate ≥18 mEq/L
- Venous pH ≥7.3
- Normalized anion gap 1
Discharge planning should include:
- Education on recognition, prevention, and management of DKA 2
- Medication changes
- Follow-up needs
- Transmission of discharge summaries to primary care providers
- Scheduling follow-up appointments 1
Special Considerations
Euglycemic DKA
- Defined as blood glucose <200 mg/dL with other DKA criteria present
- Associated with SGLT2 inhibitor use, pregnancy, reduced food intake, insulin reduction/omission 1
- Requires same management approach as traditional DKA
SGLT2 Inhibitors
Perioperative Management
- Monitor blood glucose every 2-4 hours while NPO
- Administer short or rapid-acting insulin as needed
- Target perioperative glucose: 80-180 mg/dL 2
Prevention of Recurrent DKA
- Patient education on sick-day management
- Ensure access to insulin and supplies
- Regular follow-up with healthcare providers
- Identification and management of precipitating factors 1
Complications to Watch For
- Cerebral edema (particularly in pediatric patients)
- Hypoglycemia from excessive insulin
- Hypokalemia from insulin therapy and inadequate replacement
- Hyperchloremic metabolic acidosis from excessive normal saline
- Acute respiratory distress syndrome
- Thromboembolism 4
By following this structured approach to DKA management, clinicians can effectively treat this serious condition while minimizing complications and reducing mortality.