Management of Diabetic Ketoacidosis (DKA)
The management of diabetic ketoacidosis requires immediate intervention with fluid resuscitation, insulin therapy, electrolyte replacement, and identification and treatment of precipitating factors. 1
Initial Assessment and Classification
DKA severity is classified as:
| 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 |
Patients with severe DKA (pH <7.00), altered mental status, hemodynamic instability, severe complications, or hyperosmolarity >320 mOsm/kg should be admitted to the ICU 1.
Treatment Algorithm
1. Fluid Resuscitation
- Infuse isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour or 1-1.5 L in the first hour 1
- Subsequent fluid choice depends on hydration status, electrolytes, urine output, and corrected serum sodium 1
- Continue fluid replacement until hemodynamic stability is achieved
2. Insulin Therapy
- Start continuous IV regular insulin at 0.1 U/kg/hour without bolus after initiating fluid therapy 1
- Continue insulin until resolution of ketoacidosis (pH >7.3, bicarbonate ≥18 mEq/L) 1
- Administer basal insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia 2, 1
3. Electrolyte Management
- Potassium replacement is critical and should begin when serum levels fall below 5.5 mEq/L (assuming adequate urine output): 1
- If K+ <3.3 mEq/L: Hold insulin and give 40 mEq/hr until K+ >3.3 mEq/L
- If K+ 3.3-5.2 mEq/L: Add 20-30 mEq potassium to each liter of IV fluid
- If K+ >5.2 mEq/L: Do not add potassium, check levels every 2 hours
- Phosphate replacement is not routinely recommended but may be indicated for patients with serum phosphate <1.0 mg/dL 1
4. Bicarbonate Therapy
- Generally not recommended for most DKA patients 2, 1
- Consider only if pH <6.9 or in severe acidosis with hemodynamic instability 1, 3
5. Monitoring
- Hourly assessment of vital signs, mental status, blood glucose, electrolytes (especially potassium), pH, and anion gap until stable 1
- Adjust insulin infusion rate based on glucose response
- Monitor for signs of cerebral edema, particularly in pediatric patients 3
Resolution Criteria
DKA resolution is defined as: 1
- Glucose <200 mg/dL
- Serum bicarbonate ≥18 mEq/L
- Venous pH >7.3
Special Considerations
Transition to Subcutaneous Insulin
- Administer basal insulin 2-4 hours before discontinuing IV insulin 2
- This overlap is essential to prevent recurrence of ketoacidosis 2, 1
Nutrition
- Early initiation of oral nutrition has been shown to reduce ICU and hospital length of stay 3
Airway Management
- For respiratory distress, intubation and mechanical ventilation may be necessary rather than BiPAP due to aspiration risk 3
Discharge Planning
- Develop a structured discharge plan tailored to the individual 2, 1
- Provide diabetes education including:
- Blood glucose self-monitoring techniques
- Insulin administration
- Sick-day management protocols
- Recognition of DKA warning signs
- Follow-up appointment scheduling 1
Common Pitfalls to Avoid
- Delayed potassium replacement can lead to life-threatening arrhythmias 1
- Rapid correction of hyperglycemia can cause cerebral edema, particularly in children 3, 4
- Failure to identify and treat the precipitating cause (infection, medication non-adherence, new-onset diabetes) 5
- Discontinuing IV insulin before adequate resolution of ketoacidosis 2, 1
- Inadequate transition from IV to subcutaneous insulin 2
The mortality rate for DKA is approximately 5%, with poorer outcomes in extreme ages and patients presenting with coma or hypotension 1. Proper management following these guidelines can significantly improve patient outcomes.