Treatment of Diabetic Ketoacidosis (DKA)
The management of DKA requires immediate fluid resuscitation with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour or 1-1.5 L in the first hour, followed by continuous intravenous regular insulin at 0.1 U/kg/hour without bolus, and careful electrolyte monitoring and replacement. 1
Diagnosis and Severity Assessment
DKA is characterized by:
- Hyperglycemia (typically >250 mg/dL, though euglycemic DKA can occur)
- Metabolic acidosis (pH <7.3, serum bicarbonate <18 mEq/L)
- Elevated ketones in blood or urine 1, 2
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 |
Treatment Algorithm
1. Fluid Resuscitation
- First hour: Infuse isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour or 1-1.5 L to expand intravascular volume and restore renal perfusion 1
- Subsequent hours: Continue fluid replacement based on hemodynamic status and electrolyte levels
- Goal: Correct dehydration, improve tissue perfusion, and enhance insulin sensitivity
2. Insulin Therapy
- Initial: Start continuous IV regular insulin at 0.1 U/kg/hour without bolus 1
- Recent evidence shows insulin boluses increase adverse effects (particularly hypokalemia) without significantly improving time to DKA resolution 3
- Adjustment: Titrate insulin to achieve blood glucose reduction of approximately 50 mg/dL per hour 4
- Transition: When DKA resolves (glucose <200 mg/dL, bicarbonate ≥18 mEq/L, venous pH >7.3), administer subcutaneous basal insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia 5, 1
3. Electrolyte Management
- Potassium: Check levels every 4-6 hours initially 1
- If K+ <3.3 mEq/L: Hold insulin and give potassium replacement until >3.3 mEq/L
- If K+ 3.3-5.3 mEq/L: Add 20-30 mEq potassium to each liter of IV fluid
- If K+ >5.3 mEq/L: Withhold potassium replacement and monitor closely
- Phosphate: Consider replacement if severe hypophosphatemia develops
- Bicarbonate: Generally not recommended unless severe acidosis (pH <7.0) persists 5
4. Glucose Monitoring and Adjustment
- Check blood glucose every 1-2 hours until stable
- When glucose reaches 200 mg/dL, add dextrose to IV fluids (D5W or D10W) and continue insulin infusion to clear ketones 1, 6
5. Monitoring for Complications
- Cerebral edema: Monitor for headache, altered mental status, seizures, or bradycardia
- Hypokalemia: Most common electrolyte abnormality during treatment
- Hypoglycemia: Risk increases as ketoacidosis resolves
- Hyperchloremic metabolic acidosis: Can develop during treatment due to large volumes of normal saline
Special Considerations
ICU Admission Criteria
Patients should be admitted to ICU if they present with:
- Arterial pH <7.00
- Altered mental status (stupor/coma)
- Hemodynamic instability
- Severe hyperosmolarity (>320 mOsm/kg) 1
Resolution Criteria
DKA is considered resolved when:
- Blood 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 5, 1
- Consider adding mealtime insulin as appropriate
- Avoid interruption in insulin therapy to prevent recurrence of ketoacidosis 7
Prevention of Recurrence
- Identify and treat precipitating factors (infection, medication non-adherence, etc.)
- Provide comprehensive diabetes education
- Ensure access to insulin and supplies
- Regular follow-up with healthcare providers 2
The mortality rate for DKA is approximately 5%, with worse outcomes in patients of extreme ages and those presenting with coma or hypotension 1. Prompt recognition and appropriate management following the above protocol can significantly improve outcomes.