What are the current guidelines for managing Diabetic Ketoacidosis (DKA)?

From the Guidelines

The current guidelines for managing Diabetic Ketoacidosis (DKA) emphasize a stepwise approach focusing on fluid resuscitation, insulin therapy, electrolyte replacement, and addressing the underlying cause, with the most recent and highest quality study recommending continuous intravenous insulin as the standard of care for critically ill patients 1.

Key Components of DKA Management

• Initial treatment should begin with aggressive intravenous fluid resuscitation using isotonic saline at 15-20 mL/kg/hr (typically 1-1.5 L) in the first hour, then adjusted based on hemodynamic status.
• Insulin therapy should be initiated as a continuous IV infusion at 0.1 units/kg/hr after fluid resuscitation has begun, avoiding insulin boluses which can increase hypoglycemia risk.
• Potassium replacement is crucial when levels fall below 5.2 mEq/L, aiming to maintain serum potassium between 4-5 mEq/L.
• Blood glucose should be monitored hourly, with a target reduction of 50-70 mg/dL per hour.
• Once glucose reaches 200-250 mg/dL, add dextrose to IV fluids while continuing insulin to clear ketones.
• Bicarbonate therapy is generally not recommended unless pH is below 6.9, as several studies have shown that its use makes no difference in the resolution of acidosis or time to discharge 1.

Transition to Subcutaneous Insulin

• The transition from IV to subcutaneous insulin should occur only after ketoacidosis resolves (pH >7.3, bicarbonate >15 mEq/L, anion gap normalized) with overlap between IV insulin discontinuation and subcutaneous insulin administration to prevent rebound hyperglycemia.
• Administration of basal insulin 2–4 h prior to the intravenous insulin being stopped is recommended to prevent recurrence of ketoacidosis and rebound hyperglycemia 1.

Monitoring and Follow-up

• Frequent monitoring of vital signs, mental status, fluid balance, electrolytes, and glucose is essential.
• Clear communication with outpatient providers either directly or via hospital discharge summaries facilitates safe transition of care 1.

From the Research

Current Guidelines for Managing Diabetic Ketoacidosis (DKA)

• The management of DKA includes initial rehydration using isotonic saline, followed by potassium replacement and low-dose insulin therapy 2.
• The use of bicarbonate is not recommended in most patients 2, 3.
• Recent studies suggest that large volumes of normal saline may lead to undesirable outcomes such as hyperchloremic metabolic acidosis, and balanced solutions like lactated Ringers may be a better option for initial resuscitation 4, 3.
• Insulin is given by intravenous drip at an initial rate of about 0.1 u per kg per hour 5.
• The initial hydrating fluid is 5 percent glucose in 0.45 percent saline plus 40 mEq of potassium chloride or buffered potassium phosphate, given at a rate of 250 mL per hour 5.
• Continuous follow-up of patients using treatment algorithms and flow sheets can help to minimize adverse outcomes 2.
• Preventive measures include patient education and instructions for the patient to contact the physician early during an illness 2.

Fluid Management

• Isotonic normal saline remains the standard for initial fluid resuscitation, but balanced solutions have been shown to have faster DKA resolution 3.
• Large-volume resuscitation with isotonic normal saline is associated with increased ICU length of stay, prolonged insulin infusion, and a higher incidence of non-anion gap metabolic acidosis 4.
• The use of balanced crystalloids, such as lactated Ringers, for initial resuscitation in DKA patients may reduce the risk of complications related to hyperchloremia and improve clinical outcomes 4.

Insulin Therapy

• Current guidelines recommend using continuous IV insulin for DKA management after fluid status has been restored and potassium levels have been achieved 3.
• Subcutaneous insulin is started only after the resolution of metabolic acidosis 3.
• The British guidelines recommend using SQ insulin glargine along with continuous regular IV insulin, which has shown faster DKA resolution and shorter hospital stays compared to continuous IV insulin alone 3.

Electrolyte Replacement and Monitoring

• DKA frequently involves multiple electrolyte abnormalities, such as hypokalemia, hypophosphatemia, and hypomagnesemia, and regular monitoring is essential for DKA management 3.
• Electrolyte replacement is crucial to prevent complications such as cardiac arrhythmias and respiratory failure 3.

Nutrition and Airway Management

• Early initiation of oral nutrition has been shown to reduce intensive care unit and overall hospital length of stay 3.
• For impending respiratory failure, intubation and mechanical ventilation, with monitoring and management of acid-base and fluid status, are recommended 3.
• Bilevel positive airway pressure is not recommended due to aspiration risks 3.