What is the management of diabetic ketoacidosis?

Management of Diabetic Ketoacidosis

The management of diabetic ketoacidosis (DKA) requires immediate fluid resuscitation with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour initially, followed by insulin therapy at 0.1 U/kg/hour after 1-2 hours of fluid replacement, with careful monitoring and correction of electrolyte imbalances. 1

Diagnosis Criteria

• Blood glucose >250 mg/dL
• pH <7.3 or bicarbonate <15 mEq/L
• Presence of ketones
• Essential laboratory tests:
  • Plasma glucose
  • Blood urea nitrogen/creatinine
  • Serum ketones (β-hydroxybutyrate)
  • Electrolytes
  • Arterial blood gases
  • Complete blood count
  • Urinalysis 1

Treatment Algorithm

1. Initial Fluid Resuscitation

• Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour for the first 1-2 hours
• After initial bolus, switch to 0.45-0.75% NaCl at a rate calculated to replace deficit over 24-48 hours
• When glucose reaches 250 mg/dL, add 5-10% dextrose to IV fluids while continuing insulin infusion 1

2. Insulin Therapy

• Start 1-2 hours after beginning fluid replacement
• Continuous intravenous insulin infusion at 0.1 U/kg/hour (5-7 U/h in adults)
• Target glucose reduction: 50-75 mg/dL per hour
• If glucose does not decrease by at least 50 mg/dL in first hour:
  • Check hydration status
  • If adequate, double insulin infusion rate hourly until stable decline achieved 1

3. Electrolyte Management

• Potassium replacement:
  • Begin when serum K+ <5.5 mEq/L and adequate urine output confirmed
  • Add 20-30 mEq potassium (2/3 KCl and 1/3 KPO₄) in each liter of infusion fluid
• Phosphate replacement:
  • Consider in patients with cardiac dysfunction, anemia, respiratory depression
  • Indicated when serum phosphate <1.0 mg/dL 1

4. Monitoring

• Hourly assessment of:
  • Vital signs
  • Neurological status
  • Glucose levels
  • Fluid input/output
• Every 2-4 hours:
  • Electrolytes
  • Venous pH
  • Bicarbonate levels 1

Resolution Criteria

DKA is considered resolved when:

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

Complications and Prevention

Cerebral Edema

• Avoid overly rapid correction of osmolality (maximum 3 mOsm/kg/h)
• Avoid rapid changes in serum glucose
• Avoid excessive fluid administration
• Treatment if it occurs:
  • Mannitol or hypertonic saline infusion
  • Elevate head of bed
  • Reduce fluid administration rate
  • Consider neurosurgical consultation 1

Hypoglycemia

• Add dextrose to IV fluids when glucose reaches 250 mg/dL
• Administer D10W at 2 mL/kg if symptomatic hypoglycemia occurs 1

Special Considerations

Anemia

• Lower threshold for ICU admission in patients with both DKA and severe anemia
• Monitor cardiac function closely as anemia increases cardiac workload
• Consider phosphate replacement if serum phosphate <1.0 mg/dL
• For severe symptomatic anemia, transfuse packed red blood cells 1

Transition to Subcutaneous Insulin

• Only transition after complete resolution of ketoacidosis
• Overlap IV insulin with subcutaneous insulin by 1-2 hours 1

Common Pitfalls to Avoid

• Administering insulin bolus in pediatric patients (increases risk of cerebral edema)
• Delaying fluid resuscitation before insulin administration
• Excessive fluid administration (contributes to cerebral edema)
• Inadequate potassium monitoring and replacement
• Routine use of bicarbonate (can worsen hypokalemia and increase risk of cerebral edema)
• Failing to add dextrose when glucose levels approach 250 mg/dL
• Transitioning to subcutaneous insulin too early 1

Discharge Planning

• Provide education on recognition, prevention, and management of DKA
• Include instruction on sick day management
• Ensure regular follow-up with healthcare providers 1

While there are some controversies regarding optimal fluid resuscitation rates 2, 3, the evidence strongly supports the approach outlined above for managing DKA effectively while minimizing complications.