Diabetic Ketoacidosis (DKA) Management Guidelines
The management of diabetic ketoacidosis requires immediate fluid resuscitation with normal saline (0.9% NaCl) at 4-14 ml/kg/hour initially, followed by insulin therapy at 0.1 U/kg/hour, with careful monitoring and replacement of electrolytes, particularly potassium. 1
Diagnosis and Classification
DKA is diagnosed based on the following criteria:
- Hyperglycemia (blood glucose >250 mg/dL)
- Metabolic acidosis (arterial pH <7.3, serum bicarbonate <18 mEq/L)
- Presence of ketones in blood or urine
Severity classification:
| Parameter | Mild | Moderate | Severe |
|---|---|---|---|
| Arterial pH | 7.25-7.30 | 7.00-7.24 | <7.00 |
| Serum bicarbonate (mEq/L) | 15-18 | 10-14 | <10 |
| Mental status | Alert | Alert/drowsy | Stupor/coma |
| [1] |
Treatment Algorithm
1. Fluid Resuscitation
- Initial phase: Isotonic saline (0.9% NaCl) at 4-14 ml/kg/hour, with 1-1.5 L administered during the first hour to restore circulatory volume 1
- Subsequent phase: After initial resuscitation, switch to 0.45% NaCl if the patient has hypernatremia 1
- Rate adjustment: Target correction rate should not exceed 3 mOsm/kg/hour decrease in serum osmolality 1
- Maximum correction: 10 mEq/L in the first 24 hours to avoid neurological complications 1
2. Insulin Therapy
- Initial dose for moderate to severe DKA: 0.15 U/kg regular insulin bolus followed by continuous infusion at 0.1 U/kg/hour 1
- For mild DKA: Subcutaneous or intramuscular regular insulin with initial dose of 0.4-0.6 U/kg and subsequent dose of 0.1 U/kg/hour 1
- Important caution: Delay insulin therapy if initial potassium is <3.3 mEq/L to prevent arrhythmias, cardiac arrest, and respiratory muscle weakness 1
- Intravenous administration: Clinical studies show that an initial dose of 0.5 U/h, adjusted to maintain blood glucose concentrations between 100-160 mg/dL, is effective 2
3. Electrolyte Management
- Potassium: Add to IV fluids (20-30 mEq/L) once renal function is confirmed, using 2/3 KCl and 1/3 KPO₄ for balanced replacement 1
- Monitoring: Check serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH every 2-4 hours during treatment 1
4. Bicarbonate Therapy
- Restricted use: Only administer in patients with severe acidosis (pH <6.9) 1
- Dosing: 100 mmol sodium bicarbonate in 400 ml sterile water given at 200 ml/h for adults with pH <6.9 1
Special Considerations
Pediatric Patients
- Pediatric patients are at higher risk for cerebral edema with rapid correction of glucose levels 1, 3
- Fluid resuscitation should be calculated to rehydrate evenly over at least 48 hours 3
- Risk factors for cerebral edema include severity of acidosis, greater hypocapnia, higher blood urea nitrogen at presentation, and treatment with bicarbonate 3
Hypernatremia Management
- For patients with severe hypernatremia, use hypotonic 0.45% NaCl at 4-14 ml/kg/hour with careful monitoring 1
- Avoid normal saline in hypernatremia as it would worsen the condition 1
Resolution Criteria
DKA is considered resolved when:
- Glucose <200 mg/dL
- Serum bicarbonate ≥18 mEq/L
- Venous pH ≥7.3 1
Prevention Strategies
- Patient education on early warning signs
- Sick day management protocols
- Regular blood glucose monitoring
- Ensuring uninterrupted access to diabetes medications 1
- Education on recognition and management of DKA before discharge 1
Common Pitfalls to Avoid
- Excessive fluid administration: Can cause fluid overload, especially in pediatric patients 1
- Rapid correction of hyperglycemia: Can lead to cerebral edema, particularly in children 1, 3
- Inadequate potassium monitoring: Can result in dangerous hypokalemia during insulin therapy 1
- Routine use of bicarbonate: Not recommended for most patients and may increase risk of cerebral edema in children 3, 4
- Failure to identify and treat precipitating factors: Can lead to recurrence or treatment failure 5