What is the treatment for Diabetic Ketoacidosis (DKA)?

Treatment of Diabetic Ketoacidosis (DKA)

The treatment of DKA requires immediate initiation of isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour, followed by continuous IV insulin infusion at 0.1 units/kg/hour when serum potassium is ≥3.3 mEq/L, with aggressive potassium replacement when K+ <5.5 mEq/L. 1

Initial Assessment and Diagnosis

• Confirm DKA diagnosis with:
  • Blood glucose >250 mg/dL
  • pH <7.3 or bicarbonate <15 mEq/L
  • Presence of ketones
  • Essential labs: electrolytes, BUN, creatinine, arterial blood gases, CBC, urinalysis 1

Treatment Algorithm

1. Fluid Replacement

• Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour initially 1
• Aim to correct estimated fluid deficits within 24 hours
• After initial resuscitation, adjust fluid choice based on corrected sodium:
  • If normal/elevated: switch to 0.45% NaCl at 4-14 mL/kg/hour
  • If low: continue 0.9% NaCl at similar rate 1
• Monitor for signs of fluid overload, especially in patients with renal or cardiac compromise

2. Electrolyte Replacement

• Start IV potassium replacement when serum K+ <5.5 mEq/L and adequate urine output is confirmed 1
• Use 20-40 mEq/L in each liter of fluid, with a combination of:
  • 2/3 KCl and 1/3 KPO₄ for optimal replacement 1
• Phosphate replacement is particularly important in anemic patients or if serum phosphate <1.0 mg/dL 1

3. Insulin Therapy

• Start continuous IV insulin infusion at 0.1 units/kg/hour when serum potassium is at least 3.3 mEq/L 1
• Begin insulin 1-2 hours after starting fluid replacement
• Target glucose reduction of 50-75 mg/dL per hour
• If glucose doesn't fall by 50 mg/dL in first hour:
  • Check hydration status
  • If adequate, double insulin rate every hour until stable decline is achieved 1
• Add dextrose when glucose levels approach 250 mg/dL to prevent hypoglycemia 1

4. Monitoring During Treatment

• Vital signs, mental status, urine output: hourly
• Electrolytes, glucose: every 2-4 hours
• Assess for resolution criteria:
  • Glucose <200 mg/dL
  • Normalized anion gap
  • Bicarbonate ≥18 mEq/L
  • Venous pH >7.3 1

Transition to Subcutaneous Insulin

• Consider transition when:
  • Complete resolution of acidosis
  • Patient is alert and able to eat
  • Glucose levels are stable <200 mg/dL 1
• Start subcutaneous insulin 1-2 hours before discontinuing IV insulin to avoid recurrence of hyperglycemia 1

Complications to Monitor and Prevent

Cerebral Edema

• Avoid overly rapid correction of osmolality (maximum reduction 3 mOsm/kg/h)
• Prevent rapid changes in serum glucose
• Avoid excessive fluid administration, especially in pediatric patients 1, 2

Hypoglycemia

• Monitor blood glucose frequently
• Add dextrose when glucose approaches 250 mg/dL 1, 3

Hypokalemia/Hyperkalemia

• Ensure adequate potassium replacement to prevent potentially fatal arrhythmias 1, 3
• Monitor potassium levels every 2-3 hours initially 4

Discharge Criteria

• Blood glucose <200 mg/dL
• Serum bicarbonate ≥18 mEq/L
• Venous pH ≥7.3
• Normalized anion gap
• Patient can eat adequately
• Precipitating factor identified and treated
• Appropriate insulin regimen established
• Patient educated on diabetes management, including sick day instructions 1

Special Considerations

• In patients with anemia, consider lower threshold for ICU admission as anemia can worsen tissue hypoxia in acidotic states 1
• For severe symptomatic anemia, consider packed red blood cell transfusion 1
• In patients with renal or cardiac compromise, monitor serum osmolality and frequently assess cardiac, renal, and mental status 1

While some older studies suggest alternative approaches such as low-dose insulin protocols 4 or abbreviated IV therapy 5, the most recent and comprehensive guidelines from the American Diabetes Association provide the strongest evidence for the treatment approach outlined above 1.