What is the primary treatment for diabetic ketoacidosis (DKA) in the emergency department (ED)?

Primary Treatment of Diabetic Ketoacidosis in the Emergency Department

The primary treatment for diabetic ketoacidosis (DKA) in the emergency department consists of intravenous fluid resuscitation, insulin therapy, electrolyte replacement, and identification and management of precipitating factors. 1, 2

Initial Assessment and Diagnosis

• Diagnostic criteria for DKA:

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

• Initial laboratory evaluation:

  • Blood glucose, venous blood gases, electrolytes
  • BUN, creatinine, calcium, phosphorous
  • Urinalysis 1

Treatment Algorithm

1. Fluid Resuscitation (First Priority)

• Initial fluid therapy: Isotonic saline (0.9% NaCl)

  • Adult dosing: 1-1.5 L in first hour 1, 2
  • Rate: 4-14 mL/kg/hr 2
  • Recent evidence suggests balanced fluids may lead to faster DKA resolution compared to normal saline 3

• Subsequent fluid therapy:

  • Continue with 0.9% NaCl or switch to 0.45% NaCl based on corrected serum sodium and hemodynamic status
  • Add 5-10% dextrose when blood glucose reaches 250 mg/dL while continuing insulin to clear ketones 1, 2

2. Insulin Therapy

• Standard approach: Continuous IV infusion of regular insulin

  • Initial rate: 0.1 U/kg/hour
  • No bolus is required for most patients 2
  • For mild DKA: Subcutaneous regular insulin every 4 hours may be considered 1

• Titration:

  • Adjust to achieve glucose decrease of 50-75 mg/dL/hour
  • Reduce to 0.05-0.1 U/kg/hour when glucose reaches 250 mg/dL 2
  • Continue insulin until DKA resolves (not just until normoglycemia) 1

3. Potassium Replacement

• Critical monitoring: Insulin therapy lowers serum potassium
  • Begin potassium replacement when serum K+ <5.3 mEq/L and adequate urine output is confirmed
  • Hold insulin if K+ <3.3 mEq/L until corrected 1
  • Typical replacement: 20-30 mEq in each liter of IV fluid 1

4. Bicarbonate Therapy

• Limited indications:
  • Consider only if pH <6.9
  • If pH 6.9-7.0: 50 mmol sodium bicarbonate in 200 mL sterile water over 1 hour
  • Not necessary if pH >7.0 1

5. Phosphate Replacement

• Selective use:
  • Not routinely recommended
  • Consider only for patients with cardiac dysfunction, anemia, respiratory depression, or serum phosphate <1.0 mg/dL 1

Monitoring During Treatment

• Frequent assessment:
  • Blood glucose: Every 1-2 hours
  • Electrolytes, pH, bicarbonate: Every 2-4 hours
  • Venous pH and anion gap: To monitor resolution of acidosis
  • Mental status, vital signs, fluid balance: Hourly 1, 2

Resolution Criteria

• DKA is considered resolved when:
  • Glucose <200 mg/dL
  • Serum bicarbonate ≥18 mEq/L
  • Venous pH >7.3 1, 2

Transition to Subcutaneous Insulin

• Start subcutaneous insulin 1-2 hours before discontinuing IV insulin
• Initial dose: 0.6-1.0 U/kg/day divided into basal and bolus doses
• Continue IV insulin for 1-2 hours after first subcutaneous dose 2

Common Pitfalls and Caveats

1. Monitoring ketones incorrectly:

   • Nitroprusside method doesn't measure β-hydroxybutyrate (the predominant ketone in DKA)
   • During treatment, β-hydroxybutyrate converts to acetoacetate, potentially making ketosis appear worse 1

2. Premature discontinuation of insulin:

   • Insulin should be continued until DKA resolves, not just until blood glucose normalizes
   • Hyperglycemia resolves before ketoacidosis 1

3. Inadequate monitoring for complications:

   • Cerebral edema (especially in pediatric patients)
   • Hypoglycemia
   • Hypokalemia
   • Hypophosphatemia 1, 2

4. Failure to identify and treat precipitating factors:

   • Infection
   • Medication non-adherence
   • New-onset diabetes
   • Cardiovascular events 4, 5

By following this systematic approach to DKA management, mortality can be significantly reduced while optimizing patient outcomes and resource utilization 1, 6.