What is the management approach for diabetic ketoacidosis (DKA)?

Management of Diabetic Ketoacidosis (DKA)

The management of diabetic ketoacidosis requires immediate fluid resuscitation with isotonic saline, followed by insulin therapy, potassium replacement, and treatment of underlying causes, with continuous monitoring of clinical and laboratory parameters until resolution of metabolic acidosis. 1, 2

Diagnostic Criteria

• Plasma glucose >250 mg/dL
• Arterial pH <7.30
• Serum bicarbonate <18 mEq/L
• Presence of significant ketonemia and ketonuria 2

Initial Assessment and Stabilization

• Assess airway, breathing, circulation
• Obtain IV access
• Initiate cardiac monitoring
• Check vital signs, mental status, and hydration status
• Laboratory evaluation: blood glucose, electrolytes, arterial blood gases, complete blood count, urinalysis for ketones
• Identify and treat precipitating factors (infection, myocardial infarction, stroke, medication non-adherence) 1

Treatment Protocol

1. Fluid Resuscitation

• Begin with isotonic saline (0.9% NaCl)
• Initial rate: 500 mL/hour for first 2-3 hours (15-20 mL/kg/hr in first hour for children)
• After initial resuscitation, continue with 0.45% saline with added glucose when blood glucose falls below 200-250 mg/dL
• Total fluid deficit should be replaced over 24-48 hours 1, 2, 3

2. Insulin Therapy

• Start continuous intravenous regular insulin at 0.1 units/kg/hour after fluid resuscitation has begun
• Continue until resolution of metabolic acidosis
• If glucose falls too rapidly (>100 mg/dL/hour), add dextrose to IV fluids but maintain insulin infusion to clear ketones
• Transition to subcutaneous insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia 1, 3

3. Electrolyte Management

• Potassium: Start replacement when serum potassium <5.2 mEq/L and patient is producing urine
  • Typical replacement: 20-30 mEq in each liter of IV fluid
  • Monitor levels every 2-4 hours
• Phosphate: Consider replacement if severe hypophosphatemia develops
• Magnesium: Replace if deficient 1, 3

4. Bicarbonate Therapy

• Generally not recommended in DKA management
• Only consider when arterial pH <6.9 in adults
• Not recommended in pediatric DKA regardless of pH 1, 2

5. Monitoring

• Hourly vital signs and neurological checks
• Capillary blood glucose every 1-2 hours
• Electrolytes, BUN, creatinine every 2-4 hours
• Arterial blood gases as needed based on clinical status
• Continuous cardiac monitoring 1, 2

Special Considerations

Cerebral Edema Prevention (particularly important in children)

• Avoid rapid correction of hyperglycemia
• Aim for glucose reduction of 50-100 mg/dL/hour
• Avoid hypotonic fluids in initial resuscitation
• Maintain glucose between 150-250 mg/dL during treatment 3, 4

Transition to Subcutaneous Insulin

• Start subcutaneous insulin 2-4 hours before discontinuing IV insulin
• Calculate total daily dose based on patient's weight and insulin sensitivity
• Divide into basal and bolus components
• Ensure patient can eat and drink before transition 1

Discharge Planning

• Diabetes education before discharge
• Medication reconciliation with attention to access
• Scheduled follow-up visits after discharge
• Sick day management education
• Identification of precipitating factors and strategies to prevent recurrence 1, 2

Common Pitfalls to Avoid

1. Discontinuing IV insulin too early (before resolution of acidosis)
2. Failing to replace potassium adequately
3. Using bicarbonate unnecessarily
4. Not identifying and treating the underlying cause
5. Transitioning to subcutaneous insulin without overlap with IV insulin
6. Rapid correction of hyperglycemia, especially in pediatric patients 1, 2, 3, 4

The most recent evidence from 2024 suggests that balanced IV solutions may lead to faster DKA resolution compared to normal saline, and early use of subcutaneous glargine insulin alongside IV insulin may reduce hospital length of stay 3. However, the American Diabetes Association guidelines still recommend isotonic saline as the standard initial fluid 1, 2.