What is the assessment and management plan for diabetic ketoacidosis (DKA)?

Assessment and 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. 1

Diagnosis and Assessment

DKA is characterized by:

• Diagnostic Criteria:

  • Hyperglycemia (blood glucose >250 mg/dL) or known diabetes
  • Metabolic acidosis (pH <7.30, serum bicarbonate <18 mEq/L)
  • Ketosis (elevated serum or urine ketones)
  • Anion gap >10 mEq/L 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

• Initial Evaluation:

  • Complete metabolic panel (electrolytes, BUN, creatinine)
  • Arterial or venous blood gas
  • Serum ketones
  • Complete blood count
  • Urinalysis
  • ECG
  • Consider: amylase, lipase, blood cultures, chest X-ray 1, 2

• Identify Precipitating Factors:

  • Infection
  • Myocardial infarction
  • Stroke
  • Medication non-adherence
  • Newly diagnosed diabetes 1

Management Plan

1. Fluid Resuscitation

• Initial Fluid Therapy:

  • Normal saline (0.9% NaCl) at 10-20 ml/kg/hr during first hour
  • Not to exceed 50 ml/kg over first 4 hours 1

• Subsequent Fluid Choice:

  • When blood glucose reaches 250-300 mg/dL, switch to 5% dextrose with 0.45% NaCl
  • If corrected serum sodium is normal or elevated: use 0.45% NaCl
  • If corrected serum sodium is low: continue 0.9% NaCl 1

• Calculate Corrected Sodium:

  • For each 100 mg/dL glucose >100 mg/dL, add 1.6 mEq to sodium value 1

2. Insulin Therapy

• Continuous IV Insulin:

  • Start at 0.1 units/kg/hour after confirming serum potassium >3.3 mEq/L
  • Target glucose reduction: 50-75 mg/dL per hour 1

• Transition to Subcutaneous Insulin:

  • Administer basal insulin 2-4 hours before stopping IV insulin
  • Continue IV insulin until DKA resolves (not just until blood glucose normalizes) 1

3. Electrolyte Management

• Potassium Replacement:

  • If K+ <3.3 mEq/L: Hold insulin, give potassium until >3.3 mEq/L
  • If K+ 3.3-5.3 mEq/L: Add 20-30 mEq potassium to each liter of IV fluid
  • If K+ >5.3 mEq/L: Hold potassium replacement 1

• Monitoring:

  • Check electrolytes, BUN, creatinine every 2-4 hours initially
  • Monitor potassium levels every 2-4 hours 1

4. Monitoring and Complications

• Vital Signs:

  • Check heart rate, blood pressure, respiratory rate hourly
  • Monitor mental status hourly 1

• Watch for Cerebral Edema:

  • Warning signs: headache, decreased mental status, irritability, abnormal pupillary responses
  • Occurs in 0.5-0.9% of DKA episodes 1

• ICU Admission Criteria:

  • Arterial pH <7.00
  • Altered mental status (stupor/coma)
  • Hemodynamic instability
  • Severe hyperosmolarity (>320 mOsm/kg) 1

5. Resolution Criteria

DKA is resolved when:

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

Special Considerations

• Bicarbonate Administration: Not recommended for routine use in DKA management 1

• Euglycemic DKA:

  • Can occur with SGLT-2 inhibitor use
  • Diagnosis based on ketoacidosis despite normal or only mildly elevated glucose 2

• Chronic Kidney Disease and Pregnancy:

  • Require special attention and modified protocols
  • Limited data available; recommendations based on case series and expert opinion 3

• Discharge Planning:

  • Provide diabetes education
  • Review medication regimen, especially insulin administration
  • Schedule follow-up appointment 1

Pitfalls to Avoid

1. Premature Discontinuation of Insulin: Continue insulin until ketoacidosis resolves, not just until blood glucose normalizes 1

2. Inadequate Potassium Monitoring: Insulin drives potassium intracellularly, potentially causing dangerous hypokalemia 1

3. Overly Rapid Fluid Correction: Monitor for fluid overload in elderly patients and those with renal or cardiac disease 1, 4

4. Missing Euglycemic DKA: Particularly in patients on SGLT-2 inhibitors 2

5. Failure to Identify and Treat Precipitating Factors: Addressing underlying causes is essential for successful treatment 1, 5