What is the primary treatment approach for managing Diabetic Ketoacidosis (DKA) in the Intensive Care Unit (ICU)?

Management of Diabetic Ketoacidosis (DKA) in the ICU

Continuous insulin infusion therapy is the primary treatment approach for managing moderate-to-severe diabetic ketoacidosis (DKA) in the Intensive Care Unit (ICU), preceded by aggressive fluid resuscitation with 0.9% saline at 15-20 ml/kg/h during the first hour. 1, 2

Initial Management Algorithm

1. Fluid Resuscitation

• Begin with 0.9% saline at 15-20 ml/kg/h (approximately 1-1.5 L in average adult) during first hour 1
• Restore intravascular volume to ensure perfusion of vital organs
• Continue fluid replacement based on hemodynamic status and electrolyte levels
• Consider balanced solutions which may lead to faster DKA resolution 3

2. Insulin Therapy

• Initiate insulin only after initial fluid resuscitation and when glucose levels stop decreasing with hydration alone 1
• Administer regular insulin bolus of 0.1 U/kg IV, followed by continuous infusion at 0.1 U/kg/h 1
• Target glucose reduction rate: 50-70 mg/dl per hour 1
• Monitor blood glucose every 1-2 hours to assess progression 1

3. Electrolyte Management

• Potassium: Start supplementation when serum levels <5.5 mEq/L and adequate diuresis is present
  • Add 20-30 mEq/L of potassium (2/3 KCl and 1/3 KPO₄) to IV fluids 1
  • Hypokalaemia is common (50%) during treatment and severe hypokalaemia (<2.5 mEq/L) increases mortality 2
• 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

Monitoring During Treatment

• Blood glucose: Every 1-2 hours 1
• Serum electrolytes, urea, creatinine: Every 2-4 hours 1
• Venous pH and anion gap: To assess resolution of acidosis 1
• β-hydroxybutyrate in blood: Preferred method for monitoring ketones 1
• Hemodynamic status, fluid balance, and neurological status: Continuous monitoring 1

Resolution Criteria for DKA

DKA is considered resolved when:

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

Special Considerations

Transition from IV to Subcutaneous Insulin

Transition when:

• Glucose measurements stable for at least 4-6 hours
• Normal anion gap and resolution of acidosis
• Hemodynamic stability (not on vasopressors)
• Stable nutrition plan
• Stable IV insulin infusion rates 2

To calculate subcutaneous insulin dose:

• Estimate from average insulin infused during previous 12 hours
• Example: 1.5 units/hour average = 36 units/24 hours total daily dose 2

Special Populations

• Euglycemic DKA: Requires same management approach as traditional DKA; associated with SGLT2 inhibitor use, pregnancy, reduced food intake 1
• Cardiac surgery patients: May benefit from lower glucose range (100-140 mg/dL) using computerized algorithms 2
• Elderly patients or those with cardiac/renal compromise: Require closer monitoring to avoid fluid overload 1

Complications to Avoid

• Hypoglycemia: Monitor glucose frequently and adjust insulin rates accordingly
• Cerebral edema: Avoid rapid overcorrection of hyperglycemia 3
• Electrolyte imbalances: Regular monitoring and replacement as needed
• Fluid overload: Especially in elderly or those with cardiac/renal compromise 1

Alternative Approaches

While continuous insulin infusion is the standard of care for moderate-to-severe DKA in the ICU, some evidence suggests:

• British guidelines recommend using subcutaneous insulin glargine along with continuous IV insulin for potentially faster DKA resolution and shorter hospital stays 3
• Patients with mild-to-moderate DKA might be treated with frequent subcutaneous insulin injections 2

By following this structured approach to DKA management in the ICU, focusing on fluid resuscitation, insulin therapy, and electrolyte management with careful monitoring, mortality and complications can be significantly reduced.