What is the best approach to manage Diabetic Ketoacidosis (DKA)?

Management of Diabetic Ketoacidosis (DKA)

The optimal management of DKA requires immediate implementation of continuous intravenous insulin, aggressive fluid resuscitation, electrolyte replacement, and identification and treatment of underlying precipitating factors. 1

Initial Assessment and Classification

DKA severity can be 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

ICU 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

Step-by-Step Management Algorithm

1. Fluid Resuscitation

• Initial fluid: Normal saline (0.9% NaCl) at 10-20 ml/kg/hr during first hour, not exceeding 50 ml/kg over first 4 hours 1
• Calculate corrected sodium: For each 100 mg/dL glucose >100 mg/dL, add 1.6 mEq to sodium value
• After initial resuscitation:
  • If corrected sodium normal/elevated: Use 0.45% NaCl
  • If corrected sodium low: Continue 0.9% NaCl
• When blood glucose reaches 250-300 mg/dL: Switch to 5% dextrose with 0.45% NaCl 1
• Target: Correct estimated deficits within 24 hours

2. Insulin Therapy

• Before starting insulin: Ensure serum potassium >3.3 mEq/L 1, 2
• Start continuous IV insulin at 0.1 units/kg/hour
• Target glucose reduction: 50-75 mg/dL per hour
• When blood glucose reaches 250-300 mg/dL:
  • Add 5% dextrose to IV fluids
  • Continue insulin infusion at lower rate (consider reducing to 0.05 units/kg/hour)
• Continue insulin until ketoacidosis resolves (not just until blood glucose normalizes) 1
• Administer basal insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia 1

3. Potassium Replacement

• Monitor potassium every 2-4 hours initially
• Replacement protocol:
  • K+ <3.3 mEq/L: Hold insulin, give 20-30 mEq/hr until >3.3 mEq/L
  • K+ 3.3-5.3 mEq/L: Add 20-30 mEq potassium to each liter of IV fluid
  • K+ >5.3 mEq/L: Hold potassium replacement, continue monitoring 1

4. Monitoring

• Vital signs: Check hourly (heart rate, blood pressure, respiratory rate, mental status)
• Laboratory monitoring every 2-4 hours initially:
  • Electrolytes, BUN, creatinine
  • Arterial or venous pH
  • Blood glucose
• Neurological status: Monitor hourly for signs of cerebral edema
  • Warning signs: Headache, decreased mental status, irritability, abnormal pupillary responses 1, 2

5. DKA Resolution Criteria

• 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

Cerebral Edema

• Occurs in 0.5-0.9% of all DKA episodes
• Watch for headache, decreased mental status, irritability, abnormal pupillary responses, and rising blood pressure with decreasing heart rate 1

Hypoglycemia Prevention

• Monitor blood glucose frequently
• Be alert for symptoms of hypoglycemia which may include:
  • Sweating, drowsiness, dizziness, palpitations, anxiety, tremor, blurred vision, hunger, slurred speech
  • Severe symptoms: disorientation, seizures, unconsciousness 2
• Patients with frequent episodes of hypoglycemia may need changes in therapy, meal plans, or exercise programs 2

SGLT2 Inhibitor-Associated DKA

• Be aware of euglycemic DKA risk in patients on SGLT2 inhibitors 3, 4

Discharge Planning

Before discharge:

• Educate on diabetes management and self-monitoring
• Review medication regimen, especially insulin administration
• Provide clear instructions on when to seek medical attention
• Schedule follow-up appointment 1

Common 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, 2

3. Overlooking precipitating factors: Always identify and treat underlying causes (infection, myocardial infarction, stroke, medication non-adherence) 1, 5

4. Fluid overload: Monitor for signs of fluid overload, especially in elderly patients and those with renal or cardiac disease 1

5. Missing early signs of cerebral edema: This rare but serious complication requires immediate intervention 1