What is the management of diabetic ketoacidosis (DKA)?

Management of Diabetic Ketoacidosis (DKA)

The management of diabetic ketoacidosis requires immediate implementation of continuous intravenous insulin, aggressive fluid resuscitation, electrolyte replacement, and identification and treatment of underlying precipitating factors.

Initial Assessment and Diagnosis

• DKA is characterized by:

  • Hyperglycemia (though euglycemic DKA can occur, especially with SGLT2 inhibitors)
  • Metabolic acidosis (pH <7.3, serum bicarbonate <18 mEq/L)
  • Ketosis (elevated serum or urine ketones)

• DKA severity classification 1:

  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

Immediate Management

1. Fluid Resuscitation

• Begin with normal saline (0.9% NaCl) at 10-20 ml/kg/hr during the first hour, not exceeding 50 ml/kg over the first 4 hours 1
• After initial resuscitation, switch to 0.45% NaCl (half-normal saline) if corrected serum sodium is normal or elevated 1
• When blood glucose reaches 250-300 mg/dL, add 5% dextrose to IV fluids while continuing insulin infusion at a lower rate 1
• Target fluid replacement should aim to correct estimated deficits within 24 hours 1
• Monitor for fluid overload in elderly patients and those with renal or cardiac disease 1

2. Insulin Therapy

• Start continuous intravenous insulin infusion at 0.1 units/kg/hour after confirming serum potassium is >3.3 mEq/L 1
• Target glucose reduction: 50-75 mg/dL per hour 1
• If glucose does not fall by 50 mg/dL in the first hour:
  • Check hydration status
  • Consider doubling the insulin infusion rate 1
• When blood glucose reaches 250-300 mg/dL:
  • Add 5% dextrose to IV fluids
  • Continue insulin infusion (may reduce rate) to prevent rebound ketoacidosis 2

3. Electrolyte Management

• Potassium replacement 1:
  • If K+ <3.3 mEq/L: Hold insulin, give potassium until >3.3 mEq/L
  • If K+ 3.3-5.3 mEq/L: Add 20-40 mEq/L potassium to IV fluids
  • If K+ >5.3 mEq/L: Hold potassium replacement, monitor closely
• Monitor electrolytes every 2-4 hours initially 1
• Calculate corrected sodium: For each 100 mg/dL glucose >100 mg/dL, add 1.6 mEq to sodium value 1

4. Bicarbonate Therapy

• Bicarbonate administration is generally not recommended for routine use in DKA management 1
• Sodium bicarbonate is indicated only in cases of severe acidosis (pH <7.0) with circulatory insufficiency or life-threatening hyperkalemia 3

Monitoring During Treatment

• Check glucose every 1-2 hours initially 1
• Monitor electrolytes, BUN, creatinine, and arterial/venous pH every 2-4 hours 1
• Perform frequent vital sign checks (hourly) including mental status assessment 1
• Watch for signs of cerebral edema: headache, decreased mental status, irritability, abnormal pupillary responses, rising blood pressure with decreasing heart rate 1
• Target decrease in serum osmolality should not exceed 3 mOsm/kg/hour 1

Criteria for DKA Resolution

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

Transition from IV to Subcutaneous Insulin

• Administer basal insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia and recurrence of ketoacidosis 2
• Recent studies suggest that administering a low dose of basal insulin analog in addition to IV insulin infusion may prevent rebound hyperglycemia without increased hypoglycemia risk 2

Special Considerations

• ICU admission criteria 1:

  • Arterial pH <7.00
  • Altered mental status (stupor/coma)
  • Hemodynamic instability
  • Severe associated complications
  • Severe hyperosmolarity (>320 mOsm/kg)

• For patients with mild or moderate uncomplicated DKA:

  • Subcutaneous rapid-acting insulin analogs in the emergency department or step-down units may be a safe and cost-effective alternative to IV insulin 2
  • Ensure adequate fluid replacement and frequent monitoring if this approach is used

Discharge Planning

Before discharge, ensure 2:

• Identification of healthcare professionals who will provide diabetes care
• Patient education on diabetes management, glucose monitoring, and when to seek medical attention
• Clear instructions on medication regimen, especially insulin administration
• Follow-up appointment scheduled prior to discharge

Common Pitfalls to Avoid

1. Failure to identify and treat the underlying precipitating cause (infection, myocardial infarction, stroke, medication non-adherence)
2. Inadequate fluid resuscitation or too rapid correction of osmolality
3. Premature discontinuation of IV insulin before resolution of ketoacidosis
4. Failure to transition appropriately from IV to subcutaneous insulin
5. Inadequate monitoring of electrolytes, especially potassium
6. Overlooking the possibility of euglycemic DKA, particularly in patients taking SGLT2 inhibitors

By following this structured approach to DKA management with careful attention to fluid, insulin, and electrolyte therapy, while monitoring for complications and treating underlying causes, mortality from DKA can be significantly reduced.