What are the steps for managing Diabetic Ketoacidosis (DKA)?

Management of Diabetic Ketoacidosis (DKA): Step-by-Step Approach

DKA treatment requires immediate administration of insulin and fluid replacement under specialized medical supervision in a hospital setting, with the goal of reducing glucose levels by 50-100 mg/dL per hour. 1

Diagnosis and Classification

• Diagnostic criteria:

  • Hyperglycemia (blood glucose >250 mg/dL)
  • Acidosis (pH <7.3)
  • Bicarbonate <15 mEq/L
  • Ketonemia/ketonuria 1

• Severity classification:

  • Mild: pH 7.2-7.3, bicarbonate 15-18 mEq/L
  • Moderate: pH 7.1-7.2, bicarbonate 10-15 mEq/L
  • Severe: pH <7.1, bicarbonate <10 mEq/L 1

Initial Assessment and Monitoring

• Essential laboratory tests:

  • Plasma glucose
  • Blood urea nitrogen/creatinine
  • Serum ketones
  • Electrolytes (especially potassium)
  • Serum osmolality
  • Arterial blood gases
  • Complete blood count
  • Urinalysis 1

• Monitoring schedule:

  • Blood glucose: every 1-2 hours
  • Electrolytes, BUN, creatinine: every 2-4 hours
  • Venous pH and anion gap: every 2-4 hours
  • Continuous cardiac monitoring for T-wave changes 1

Treatment Algorithm

1. Fluid Resuscitation

• Initial phase: Isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour 1
• Subsequent fluid: Choice based on hydration status and electrolytes
• Total deficit replacement: Can be completed orally once patient tolerates oral fluids 2
• Caution: Avoid excessive saline resuscitation to reduce risk of cerebral edema, especially in children 3

2. Insulin Therapy

• Timing: Begin 1-2 hours after starting fluid replacement 1
• Dosing: Continuous IV insulin infusion at 0.1 U/kg/hour 1
• Important: Avoid insulin bolus, especially in children (increases risk of cerebral edema) 1, 3
• Alternative approach: In resource-limited settings without ICU access, subcutaneous rapid-acting insulin analog at 0.15 U/kg every 2-3 hours until resolution of metabolic acidosis 2

3. Electrolyte Replacement

• Potassium:

  • Add when levels <5.5 mEq/L and renal function is adequate
  • Add 20-30 mEq/L potassium to IV fluids (2/3 KCl and 1/3 KPO4)
  • If initial potassium is low, temporarily delay insulin and first bring potassium level close to 4 mmol/L 1, 3

• Bicarbonate:

  • Generally not recommended for children with DKA 3
  • In adults, consider only if pH <7.20 and bicarbonate <12 mmol/L with hemodynamic instability 3

• Phosphate:

  • Consider replacement in patients with cardiac dysfunction, anemia, respiratory depression, or serum phosphate <1.0 mg/dL 1

4. Identify and Treat Precipitating Factors

• Common precipitants include:
  • Infections
  • New diagnosis of diabetes
  • Insulin non-adherence
  • SGLT2 inhibitor use 4

Resolution Criteria and Transition to Subcutaneous Insulin

• DKA resolution is indicated by:

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

• Transition to subcutaneous insulin:

  • Continue IV insulin for 1-2 hours after first subcutaneous dose
  • For Type 1 diabetes: Multiple daily injections or insulin pump therapy
  • For Type 2 diabetes: Consider metformin after resolution of ketosis 1
  • Alternative approach: Initiate intermediate-acting (NPH) insulin at 0.6-1 U/kg/day approximately 12 hours after treatment initiation 2

Complications and How to Avoid Them

• Cerebral edema (most common cause of mortality, especially in children):

  • Avoid insulin bolus
  • Avoid excessive fluid resuscitation
  • Prevent rapid decreases in effective plasma osmolality 3

• Hypokalemia:

  • Monitor potassium closely
  • Ensure adequate potassium replacement before and during insulin therapy 3

• Hypoglycemia:

  • Add dextrose to IV fluids when glucose falls below 250 mg/dL
  • Continue insulin to clear ketones 1

Discharge Planning

• Education on:

  • Recognition of DKA symptoms
  • Sick day management
  • Insulin administration
  • Blood glucose monitoring 1

• Follow-up:

  • Schedule appointments with healthcare providers
  • Ensure transmission of discharge summaries to primary care providers 1

• Insulin regimen:

  • Adjust to 0.4-0.7 U/kg/day at discharge 2
  • Ensure proper education on administration

By following this structured approach to DKA management, clinicians can effectively treat this potentially life-threatening condition while minimizing complications.