What is the management approach for Diabetic Ketoacidosis (DKA)?

Management of Diabetic Ketoacidosis (DKA)

The management of diabetic ketoacidosis requires immediate administration of isotonic saline (0.9% NaCl) at 4-14 ml/kg/h for initial fluid resuscitation, followed by regular insulin at 0.1 U/kg/hour as continuous IV infusion, with careful monitoring and replacement of electrolytes, particularly potassium. 1

Diagnostic Criteria and Severity Assessment

DKA is diagnosed when all of the following criteria are met:

• Blood glucose >250 mg/dL
• Arterial pH <7.3
• Bicarbonate <15 mEq/L
• Moderate ketonuria or ketonemia 1

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 Evaluation

• Arterial blood gases
• Complete blood count with differential
• Urinalysis
• Blood glucose
• BUN, electrolytes, chemistry profile
• Creatinine
• ECG 1

Treatment Algorithm

1. Fluid Resuscitation

• Begin with 0.9% NaCl at 4-14 ml/kg/h
• Administer 1-1.5 L during the first hour to restore circulatory volume
• For patients with severe hypernatremia and hyperchloremia, switch to 0.45% NaCl at 4-14 ml/kg/h
• Target correction rate should not exceed 3 mOsm/kg/hour decrease in serum osmolality
• Maximum correction should be 10 mEq/L in the first 24 hours 1

2. Insulin Therapy

• Critical step: Check potassium level before starting insulin
• Delay insulin therapy if initial potassium is <3.3 mEq/L to prevent arrhythmias, cardiac arrest, and respiratory muscle weakness
• For moderate to severe DKA: Initial bolus of 0.15 U/kg regular insulin followed by continuous infusion at 0.1 U/kg/hour
• For mild DKA: Subcutaneous or intramuscular regular insulin can be used (initial dose 0.4-0.6 U/kg, then 0.1 U/kg/hour) 1

3. Potassium Replacement

• Start 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 1

4. Bicarbonate Therapy

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

Monitoring During Treatment

• Blood glucose, electrolytes, venous pH, bicarbonate, BUN, and creatinine every 2-4 hours
• Vital signs, fluid input/output, mental status
• Cardiac monitoring in high-risk patients 1

Potential Complications and Management

Hypoglycemia

• Common adverse event in insulin users
• Symptoms range from mild (sweating, drowsiness, dizziness) to severe (disorientation, seizures, unconsciousness)
• Treatment: Oral glucose for mild cases; IV glucose or glucagon injection for severe cases 2

Hypokalemia

• Can develop during insulin therapy
• Monitor potassium levels closely
• Replace as needed according to laboratory values 1

Cerebral Edema

• Higher risk in pediatric patients
• Avoid rapid correction of glucose levels in pediatric patients 1

Fluid Overload

• Risk increases with excessive fluid administration
• Particularly concerning in patients with cardiac or renal disease 1

Resolution Criteria and Transition to Subcutaneous Insulin

Resolution is achieved when:

• Glucose <200 mg/dL
• Serum bicarbonate ≥18 mEq/L
• Venous pH ≥7.3 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 rebound hyperglycemia 1

Special Considerations

Pregnancy

• Requires specialized management approach 1

SGLT2 Inhibitors

• Be aware that these medications can precipitate DKA, sometimes with only mildly elevated glucose levels 3

Insulin Allergy

• Rare but potentially serious complication
• If allergic reaction to human insulin occurs, synthetic insulin analogues may be considered 4

Prevention of Recurrence

• Patient education on early warning signs of DKA
• Sick day management protocols
• Proper insulin administration techniques
• Regular blood glucose monitoring
• Uninterrupted access to diabetes medications 1