What is the management of diabetic ketoacidosis (DKA)?

Management of Diabetic Ketoacidosis (DKA)

The management of diabetic ketoacidosis requires immediate fluid resuscitation with normal saline (0.9% NaCl) at 15-20 ml/kg/hr during the first hour, continuous intravenous insulin at 0.1 U/kg/hour, and correction of electrolyte imbalances, while treating the underlying precipitating cause. 1, 2

Diagnosis and Classification

DKA is characterized by:

• Hyperglycemia (blood glucose >250 mg/dL), though euglycemic DKA can occur, especially with SGLT2 inhibitor use
• Metabolic acidosis (pH <7.3, serum bicarbonate <18 mEq/L)
• Elevated serum or urine ketones

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. Initial Assessment and Monitoring

• Assess airway, breathing, circulation
• Monitor vital signs, mental status, and fluid balance
• Check blood glucose, electrolytes, renal function, arterial blood gases
• Identify precipitating factors (infection, medication non-adherence, new-onset diabetes)

2. Fluid Resuscitation

• Initial volume expansion: Normal saline (0.9% NaCl) at 15-20 ml/kg/hr during first hour (1-1.5L in average adult) 1
• After initial resuscitation, adjust fluid choice based on corrected serum sodium:
  • If normal or elevated sodium: Switch to half normal saline (0.45% NaCl)
  • If low sodium: Continue normal saline
• When serum glucose reaches 250 mg/dL, change to 5% dextrose with 0.45-0.75% NaCl 1

3. Insulin Therapy

• Start continuous IV regular insulin at 0.1 U/kg/hour without bolus 1
• Continue until resolution of DKA (glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3) 1
• Administer basal insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia and recurrence of ketoacidosis 2, 1
• For uncomplicated DKA, subcutaneous rapid-acting insulin analogs may be used in emergency department or step-down units with adequate fluid replacement and frequent monitoring 2

4. Electrolyte Management

• Potassium replacement:
  • If serum potassium <3.3 mEq/L: Hold insulin until potassium >3.3 mEq/L
  • If serum potassium 3.3-5.3 mEq/L: Add 20-30 mEq potassium to each liter of IV fluid
  • If serum potassium >5.3 mEq/L: Hold potassium replacement, check levels frequently
• Monitor and replace other electrolytes as needed

5. Admission Criteria

• Admit to ICU if:
  • Arterial pH <7.00
  • Altered mental status (stupor/coma)
  • Hemodynamic instability
  • Severe complications
  • Severe hyperosmolarity (>320 mOsm/kg) 1
• Otherwise, admit to medical floor with appropriate monitoring

Special Considerations

Euglycemic DKA

• Can occur with SGLT2 inhibitor use
• Diagnosis may be delayed due to absence of significant hyperglycemia
• Management principles remain the same, with emphasis on dextrose-containing fluids 3

Pregnancy

• Requires more aggressive treatment and monitoring
• Lower thresholds for ICU admission
• Close fetal monitoring if applicable 4

Chronic Kidney Disease

• Requires careful fluid and electrolyte management
• May need reduced insulin doses and more cautious fluid administration 4, 5

Heart Failure

• Use caution with fluid resuscitation
• Consider more frequent hemodynamic monitoring 5

Resolution Criteria and Discharge Planning

DKA resolution is defined as:

• Glucose <200 mg/dL
• Serum bicarbonate ≥18 mEq/L
• Venous pH >7.3 1

Prior to discharge:

• Identify healthcare provider for follow-up
• Ensure patient understands diabetes management, including self-monitoring of blood glucose and when to seek medical attention
• Provide education on recognition and prevention of hyperglycemia and hypoglycemia
• Review medication regimen, especially insulin administration
• Schedule outpatient follow-up prior to discharge 2

Common Pitfalls to Avoid

• Failing to identify and treat the precipitating cause
• Inadequate fluid resuscitation or excessive fluid administration in patients with heart failure
• Premature discontinuation of IV insulin before resolution of ketoacidosis
• Not administering basal insulin before stopping IV insulin
• Inadequate potassium replacement leading to hypokalemia during insulin therapy
• Overlooking euglycemic DKA, especially in patients on SGLT2 inhibitors
• Insufficient patient education to prevent recurrence

The mortality rate for DKA is approximately 5%, with worse outcomes in patients of extreme ages and those presenting with coma or hypotension 1. Proper management according to established protocols significantly improves outcomes.