Management of Diabetic Ketoacidosis (DKA)
The management of diabetic ketoacidosis requires immediate intervention with intravenous fluids, insulin therapy, electrolyte replacement, and identification and treatment of precipitating factors to reduce mortality and morbidity. 1
Diagnostic Criteria for DKA
- Blood glucose >250 mg/dL
- Venous 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 Management
Fluid Therapy
- Begin with isotonic saline (0.9% NaCl) at 1-1.5 L in the first hour for adults 1
- 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
- Consider balanced electrolyte solutions as they may lead to faster DKA resolution than 0.9% saline 2
Insulin Therapy
- Initiate continuous IV infusion of regular insulin at 0.1 U/kg/hour without bolus for most patients 1
- For mild DKA, subcutaneous rapid-acting insulin may be considered as an alternative 3, 1
- Continue insulin therapy even when glucose falls below 250 mg/dL (add dextrose to IV fluids) to clear ketones 1
Electrolyte Management
- Begin potassium replacement when serum K+ <5.3 mEq/L and adequate urine output is confirmed
- Typical replacement: 20-30 mEq in each liter of IV fluid 1
- Hold insulin therapy if K+ <3.3 mEq/L until corrected to prevent cardiac arrhythmias 1, 4
- Monitor phosphate levels and consider replacement if levels fall toward lower limits of normal 5
Bicarbonate Therapy
- Generally not recommended for routine use 3
- Consider only for severe acidosis (pH <6.9) at a dose of 50 mmol sodium bicarbonate in 200 mL sterile water over 1 hour 1
- In adults with moderately severe acidemia (pH <7.20 and bicarbonate <12 mmol/L) who are hemodynamically unstable, bicarbonate may be considered 6
- Not recommended for children with DKA due to risk of cerebral edema 6
Monitoring
- Blood glucose: Every 1-2 hours until stable
- Ketones: Every 2-4 hours until resolving (blood β-hydroxybutyrate preferred over urine ketones)
- Electrolytes, pH, and bicarbonate: Every 2-4 hours
- Vital signs, mental status, and fluid balance: Hourly 1
Resolution Criteria
DKA is considered resolved when:
- Glucose <200 mg/dL
- Serum bicarbonate ≥18 mEq/L
- Venous pH >7.3 1
Transition to Subcutaneous Insulin
- Administer basal insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia and recurrence of ketoacidosis 3
- Continue IV insulin until metabolic acidosis resolves 3
Complications and Prevention
Cerebral Edema
- Rare but potentially fatal complication, especially in children
- Risk factors: Rapid correction of hyperglycemia, excessive fluid administration, decrease in effective plasma osmolality
- Prevention: Avoid insulin bolus, excessive saline resuscitation, and rapid decrease in plasma osmolality 6
Hypoglycemia
- Monitor glucose closely, especially when adding dextrose to IV fluids
- Symptoms may include sweating, drowsiness, dizziness, anxiety, tremor, confusion 4
- Treat with oral glucose if conscious or IV glucose/glucagon if unconscious 4
Hypokalemia
- Common during insulin therapy
- Monitor potassium levels closely and replace as needed
- Can lead to cardiac arrhythmias if not addressed 4
Treatment of Precipitating Factors
- Identify and treat underlying causes such as:
Discharge Planning and Education
- Provide education on:
- Sick day management protocols
- When to check ketones
- When to seek medical attention
- Importance of never omitting insulin
- Recognition of early warning signs of DKA 1
- Arrange follow-up with primary care provider or endocrinologist 3
- Ensure medication reconciliation and access to medications 3
By following this structured approach to DKA management, focusing on fluid resuscitation, insulin therapy, electrolyte management, and treatment of underlying causes, clinicians can effectively treat this serious condition and reduce associated morbidity and mortality.