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

Diabetic Ketoacidosis (DKA) Management Protocol

The management of DKA requires immediate administration of isotonic saline (0.9% NaCl) at 15-20 ml/kg/h during the first hour, followed by insulin therapy at 0.1 U/kg/hour, with frequent monitoring of electrolytes and glucose every 2-4 hours until resolution criteria are met. 1

Initial Assessment and Diagnosis

• Diagnostic criteria for DKA:

  • Blood glucose >250 mg/dL
  • Arterial pH <7.3
  • Bicarbonate <15 mEq/L
  • Moderate ketonuria or ketonemia 2

• 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

• Initial laboratory workup:

  • Arterial blood gases
  • Complete blood count with differential
  • Urinalysis
  • Blood glucose, BUN, electrolytes, chemistry profile, creatinine
  • ECG
  • Additional tests as indicated: chest X-ray, cultures 2

Fluid Resuscitation

1. First hour: Isotonic saline (0.9% NaCl) at 15-20 ml/kg/h (typically 1-1.5 L in average adult) 2, 1

2. Subsequent fluid therapy:

   • If corrected serum sodium is normal or elevated: 0.45% NaCl at 4-14 ml/kg/h
   • If corrected serum sodium is low: 0.9% NaCl at 4-14 ml/h 2, 1
   • Target to replace estimated deficits within 24 hours
   • Do not exceed correction rate of 3 mOsm/kg/h in serum osmolality 1

3. Special considerations:

   • In patients with renal or cardiac compromise: Monitor osmolality and cardiac/renal status closely
   • In pediatric patients: Initial fluid rate of 10-20 ml/kg/h with isotonic saline, not exceeding 50 ml/kg in first 4 hours (higher risk of cerebral edema) 2, 3

Insulin Therapy

1. Initial insulin administration:

   • Start with 0.1 U/kg/hour of regular insulin as continuous IV infusion 1
   • For moderate to severe DKA: Consider initial bolus of 0.15 U/kg regular insulin 1
   • For mild DKA: Subcutaneous or IM regular insulin can be used (0.4-0.6 U/kg initially) 1

2. Important caution:

   • Delay insulin therapy if initial potassium is <3.3 mEq/L to avoid arrhythmias and cardiac arrest 1, 4

3. Insulin adjustment:

   • Continue insulin until resolution of DKA (glucose <200 mg/dL, bicarbonate ≥18 mEq/L, venous pH ≥7.3) 1
   • When blood glucose falls to <200 mg/dL, add dextrose to IV fluids while continuing insulin to clear ketones 1

Electrolyte Management

1. Potassium replacement:

   • Once renal function is assured, add 20-30 mEq/L potassium to IV fluids
   • Use 2/3 KCl and 1/3 KPO₄ for balanced replacement 2, 1
   • Monitor potassium levels every 2-4 hours

2. Bicarbonate therapy:

   • Only administer in severe acidosis (pH <6.9)
   • Recommended dose: 100 mmol sodium bicarbonate in 400 ml sterile water at 200 ml/h 1

Monitoring Protocol

1. Laboratory monitoring:

   • Blood glucose, electrolytes: Every 2-4 hours
   • Venous pH, bicarbonate, BUN, creatinine: Every 4-6 hours
   • Monitor for resolution criteria:
     • Glucose <200 mg/dL
     • Serum bicarbonate ≥18 mEq/L
     • Venous pH ≥7.3 1

2. Clinical monitoring:

   • Vital signs hourly
   • Fluid input/output
   • Mental status (especially in pediatric patients - watch for cerebral edema)
   • Cardiac monitoring in high-risk patients 2, 3

Common Pitfalls and Complications

1. Cerebral edema:

   • More common in children and adolescents
   • Risk factors: Severity of acidosis, greater hypocapnia, higher BUN at presentation, bicarbonate treatment 3
   • Warning signs: Headache, altered mental status, abnormal pupillary responses, hypertension

2. Hypokalemia:

   • Can develop rapidly during treatment due to insulin-driven intracellular potassium shift
   • Can lead to cardiac arrhythmias if not properly managed 4

3. Hypoglycemia:

   • Can occur with aggressive insulin therapy without proper glucose monitoring
   • Add dextrose when glucose falls below 200-250 mg/dL 4

4. Fluid overload:

   • Risk in patients with cardiac or renal compromise
   • Requires careful monitoring of fluid status 1

Transition and Discharge Planning

1. Transition to subcutaneous insulin:

   • Begin once DKA has resolved and patient can tolerate oral intake
   • Continue IV insulin for 1-2 hours after first subcutaneous dose to prevent recurrence

2. Patient education before discharge:

   • Recognition of early warning signs of DKA
   • Sick day management protocols
   • Proper insulin administration
   • Regular blood glucose monitoring 1

3. Follow-up:

   • Schedule prompt follow-up with healthcare provider
   • Address precipitating factors to prevent recurrence 5

This protocol provides a comprehensive approach to managing DKA with emphasis on fluid resuscitation, insulin therapy, electrolyte management, and careful monitoring to optimize outcomes and reduce complications.