Management of Diabetic Ketoacidosis: Additional Interventions
In a patient with DKA, dextrose IV bolus should be added when blood glucose falls below 250 mg/dL, while continuing insulin therapy to clear ketones. 1
Fluid and Electrolyte Management
Initial Fluid Resuscitation
- Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour for the first hour 2, 1
- For pediatric patients: Use 0.9% NaCl at 10-20 mL/kg/hour, not exceeding 50 mL/kg in first 4 hours 2
- Continue fluid replacement to correct estimated deficits within 24 hours 1
Subsequent Fluid Management
- After initial resuscitation, choose fluids based on:
Potassium Replacement
- Critical intervention: Start potassium replacement when serum K+ <5.5 mEq/L and adequate urine output is confirmed 1
- Use combination of KCl (2/3) and KPO₄ (1/3) at 20-30 mEq/L 2, 1
- Administer via calibrated infusion device at controlled rate 3
- Prioritize potassium correction before insulin if initial K+ is low 4
Dextrose Administration
- Add dextrose (D5W or D10W) when blood glucose reaches 250 mg/dL 2, 1
- This prevents hypoglycemia while continuing insulin to clear ketones
- Monitor for rebound hypoglycemia when concentrated dextrose is discontinued 5
Insulin Therapy
- Start insulin 1-2 hours after beginning fluid resuscitation 1
- Use continuous IV insulin at 0.1 units/kg/hour when K+ ≥3.3 mEq/L 1
- Target glucose reduction: 50-75 mg/dL per hour 1
- Continue insulin until DKA resolves (bicarbonate ≥18 mEq/L, pH >7.3, normalized anion gap) 1
Monitoring and Assessment
- Check vital signs, mental status every 1-2 hours
- Monitor electrolytes, glucose, venous pH every 2-4 hours 1
- Watch for signs of cerebral edema (headache, altered mental status, bradycardia, hypertension)
- Monitor for hypokalemia during insulin therapy 1, 4
Special Considerations
Sodium Bicarbonate
- Generally not recommended for routine use in DKA 6
- Consider only if pH <6.9 or in adults with pH <7.2 and bicarbonate <12 mEq/L with hemodynamic instability 6, 4
- Not recommended for children with DKA except in severe, refractory cases 4
Balanced Electrolyte Solutions
- Recent evidence suggests balanced electrolyte solutions may resolve DKA faster than 0.9% saline 7, 6
- Consider in patients at risk for hyperchloremic metabolic acidosis
Resolution Criteria
- Blood glucose <200 mg/dL
- Serum bicarbonate ≥18 mEq/L
- Venous pH >7.3
- Normalized anion gap 1
Common Pitfalls to Avoid
- Delaying dextrose administration when glucose falls below 250 mg/dL
- Discontinuing insulin when glucose normalizes before ketoacidosis resolves
- Inadequate potassium replacement leading to life-threatening hypokalemia
- Rapid correction of hyperglycemia or osmolality increasing risk of cerebral edema
- Excessive sodium bicarbonate administration potentially causing osmotic demyelination syndrome 8
Remember that while addressing hyperglycemia is important, clearing ketones with continued insulin therapy is essential for complete DKA resolution, which is why dextrose must be added when glucose levels fall below 250 mg/dL.