What is the management of Diabetic Ketoacidosis (DKA)?

From the Guidelines

Diabetic ketoacidosis (DKA) management requires prompt intervention with intravenous fluids, insulin, and electrolyte replacement, with the goal of restoring circulatory volume, resolving ketoacidosis, and correcting electrolyte imbalances, as recommended by the most recent guidelines 1. The management of DKA involves several key steps, including:

• Initiation of intravenous fluid replacement with 1-2 liters of normal saline (0.9% NaCl) in the first 1-2 hours, followed by continued fluid replacement based on hydration status
• Starting an IV insulin infusion at 0.1 units/kg/hour after the initial fluid bolus, without giving an insulin bolus to avoid increasing the risk of hypoglycemia
• Monitoring blood glucose hourly, aiming for a decrease of 50-75 mg/dL per hour, and adding dextrose (D5W or D10W) to the IV fluids when glucose reaches 200-250 mg/dL to continue clearing ketones
• Replacing potassium when levels are below 5.3 mEq/L and the patient is producing urine, aiming to maintain levels between 4-5 mEq/L, and addressing other electrolyte abnormalities, particularly phosphate and magnesium
• Monitoring serum ketones, anion gap, and pH to track resolution of ketoacidosis
• Transitioning to subcutaneous insulin only when the patient is eating, ketoacidosis has resolved (pH >7.3, bicarbonate >18 mEq/L, anion gap normalized), and the patient is clinically stable, with the first subcutaneous dose given 1-2 hours before stopping the insulin infusion to prevent rebound hyperglycemia Some key points to consider in DKA management include:
• The use of bicarbonate therapy is not generally recommended, as studies have shown no significant benefit in outcomes 1
• Phosphate replacement may be indicated in patients with cardiac dysfunction, anemia, or respiratory depression, and in those with serum phosphate concentration < 1.0 mg/dl 1
• Gradual correction of glucose and osmolality, as well as judicious use of isotonic or hypotonic saline, is recommended to avoid cerebral edema 1 The most recent guidelines recommend individualization of treatment based on a careful clinical and laboratory assessment, and emphasize the importance of addressing the underlying trigger of DKA, such as infection, medication non-adherence, or new-onset diabetes 1.

From the Research

Management of Diabetic Ketoacidosis (DKA)

The management of DKA involves several key components, including:

• Fluid replacement: Adequate fluid replacement is crucial in the management of DKA, with the goal of replacing lost fluids and electrolytes 2, 3, 4, 5.
• Insulin therapy: Low-dose insulin therapy is recommended, with the goal of reducing glucose levels and suppressing ketone production 2, 3, 4, 5.
• Electrolyte replacement: Potassium replacement is essential, as patients with DKA often have significant potassium deficits 2, 3, 4, 5.
• Identification and treatment of underlying causes: Identifying and treating the underlying cause of DKA, such as infection or non-adherence to insulin therapy, is critical to preventing recurrence 2, 3, 4, 5.
• Monitoring: Close monitoring of the patient's clinical and laboratory status is essential to adjust therapy and identify complications 2, 3, 4, 5.

Fluid Management

The choice of fluid for resuscitation in DKA is important, with recent studies suggesting that large volumes of normal saline may lead to undesirable outcomes such as hyperchloremic metabolic acidosis 6.

• Isotonic normal saline (NS) has traditionally been recommended for initial volume replacement, but recent studies suggest that balanced crystalloids, such as lactated Ringers, may be a better choice 6.
• The use of large volumes of NS has been associated with prolonged ICU length of stay, increased time on insulin infusion, and higher rates of non-anion gap metabolic acidosis 6.

Prevention

Prevention of DKA is critical, and can be achieved through:

• Patient education: Educating patients on the signs and symptoms of DKA, as well as how to manage high-risk situations, can help prevent recurrence 4, 5.
• Identifying diabetes before DKA develops: Early identification and treatment of diabetes can help prevent the development of DKA 5.
• Ensuring uninterrupted access to therapies for diabetes: Ensuring that patients have access to insulin and other therapies for diabetes can help prevent DKA 5.