Initial Management of Diabetic Ketoacidosis (DKA)
The initial management of DKA requires immediate fluid resuscitation with isotonic saline (0.9% NaCl) at 1-1.5 L in the first hour, followed by continuous IV insulin infusion at 0.1 U/kg/hour without bolus, and careful electrolyte monitoring with potassium replacement when serum K+ is <5.3 mEq/L. 1
Diagnostic Criteria for DKA
DKA is confirmed when all three criteria are present:
- Hyperglycemia (elevated blood glucose or history of diabetes)
- Presence of ketones in blood or urine
- Metabolic acidosis with high anion gap
DKA severity classification:
| Parameter | Mild | Moderate | Severe |
|---|---|---|---|
| Arterial pH | 7.25-7.30 | 7.00-7.24 | <7.00 |
| Bicarbonate (mEq/L) | 15-18 | 10-14 | <10 |
| Mental Status | Alert | Alert/drowsy | Stupor/coma |
Step-by-Step Initial Management Algorithm
1. Fluid Replacement
- Begin with isotonic saline (0.9% NaCl) at 1-1.5 L in the first hour 1
- Continue fluid replacement based on hemodynamic status and dehydration severity
- This is the most important initial step in DKA management 2
2. Insulin Therapy
- Start continuous IV infusion of regular insulin at 0.1 U/kg/hour without bolus 1
- Monitor blood glucose hourly
- Adjust insulin rate based on response
- Do not stop insulin therapy until acidosis is resolved, even if blood glucose normalizes 2
3. Electrolyte Management
- Monitor serum potassium closely
- 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
- Hold insulin if K+ <3.3 mEq/L until corrected 1
- Hypokalemia can lead to life-threatening cardiac arrhythmias 3
4. Monitoring
- Hourly assessment of:
- Vital signs
- Mental status
- Blood glucose
- Electrolytes (especially potassium)
- Arterial blood gases or venous pH
- Anion gap 1
5. ICU Admission Criteria
Patients with DKA should be admitted to ICU if they present with:
- Arterial pH <7.00
- Altered mental status (stupor/coma)
- Hemodynamic instability
- Severe associated complications
- Severe hyperosmolarity (>320 mOsm/kg) 1
Special Considerations
Identifying and Treating Precipitating Factors
- Common precipitants include:
- Infection
- Insulin omission
- New-onset diabetes
- Medications (e.g., SGLT2 inhibitors)
- Acute illness 4
- Administer broad-spectrum antibiotics if infection is suspected 5
Transition to Subcutaneous Insulin
- Administer basal insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia 1
- Only switch to subcutaneous insulin after acidosis is corrected and glucose levels are stable 2
Bicarbonate Therapy
- Consider bicarbonate replacement only if pH <7.1 5
- Use with caution as it may worsen hypokalemia and cerebral edema
Potential Complications to Monitor
- Cerebral edema: rare but potentially fatal complication with mortality rate up to 70% 1
- Hypoglycemia: monitor blood glucose frequently, especially when glucose levels approach normal 3
- Hypokalemia: can cause cardiac arrhythmias; monitor closely during insulin therapy 3
- Fluid overload: particularly concerning in patients with heart or kidney disease 4
Resolution Criteria for DKA
DKA is considered resolved when:
- Glucose <200 mg/dL
- Serum bicarbonate ≥18 mEq/L
- Venous pH >7.3 1
Remember that DKA carries a mortality rate of approximately 5%, with worse outcomes in extreme ages and in patients presenting with coma or hypotension 1. Early recognition and aggressive management are essential to improve patient outcomes.