What is the management of diabetic ketoacidosis (DKA)?

Management of Diabetic Ketoacidosis (DKA)

The management of diabetic ketoacidosis requires prompt intervention with fluid resuscitation, insulin therapy, electrolyte replacement, and identification of precipitating factors, following a structured approach as recommended by the American Diabetes Association. 1

Diagnosis and Severity Assessment

DKA severity is classified based on:

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

Diagnostic criteria include:

• Hyperglycemia (typically >250 mg/dL)
• Presence of ketones in blood or urine
• Metabolic acidosis with anion gap

Treatment 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
• After initial resuscitation:
  • If still hyperglycemic: Switch to 0.45% NaCl (half-normal saline)
  • When blood glucose reaches 250-300 mg/dL: Switch to 5% dextrose with 0.45% NaCl

Important: Consider balanced crystalloids rather than 0.9% saline for patients with hyperchloremia to prevent worsening metabolic acidosis 1

2. Insulin Therapy

• Start continuous intravenous insulin infusion at 0.1 units/kg/hour
• Critical safety check: Confirm serum potassium is >3.3 mEq/L before starting insulin
• Target glucose reduction: 50-75 mg/dL per hour
• Continue insulin until DKA resolution (bicarbonate ≥18 mEq/L, venous pH >7.3)

3. Electrolyte Management

• Potassium replacement based on serum levels:

  • K+ <3.3 mEq/L: Hold insulin, give potassium replacement until >3.3 mEq/L
  • K+ 3.3-5.2 mEq/L: Add 20-30 mEq KCl per liter of IV fluid
  • K+ >5.2 mEq/L: No replacement, monitor closely

• Bicarbonate administration:

  • Not recommended for routine use in DKA management
  • May be considered only in severe acidosis (pH <6.9) or in specific clinical scenarios

4. Monitoring

• Vital signs: Check hourly (heart rate, blood pressure, respiratory rate, mental status)
• Laboratory monitoring:
  • Electrolytes, BUN, creatinine, glucose: Every 2-4 hours initially
  • Arterial or venous pH: Every 2-4 hours until normalized
• Target decrease in serum osmolality: Not to exceed 3 mOsm/kg/hour

Special Considerations

ICU Admission Criteria

Admit to ICU if any of the following are present:

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

Cerebral Edema Monitoring

• Occurs in 0.5-0.9% of DKA episodes
• Warning signs: Headache, decreased mental status, irritability, abnormal pupillary responses, rising BP with decreasing heart rate

Special Populations

• Pregnancy: Requires more intensive monitoring and specialized care 2, 3
• Chronic kidney disease: May need adjusted fluid and electrolyte management 2, 3
• Heart failure: Requires careful fluid administration
• SGLT2 inhibitor-associated DKA: May present with euglycemic DKA (glucose <250 mg/dL) 2, 3

DKA Resolution Criteria

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

Discharge Planning

• Ensure identification of healthcare professionals for diabetes follow-up
• Provide education on diabetes management and glucose monitoring
• Give clear instructions on medication regimen, especially insulin administration
• Schedule follow-up appointment prior to discharge

Common Pitfalls to Avoid

1. Starting insulin before confirming adequate potassium levels (>3.3 mEq/L)
2. Correcting glucose too rapidly (target: 50-75 mg/dL/hour)
3. Failing to identify and treat the precipitating cause
4. Discontinuing insulin completely when glucose normalizes but acidosis persists
5. Not calculating corrected sodium (For each 100 mg/dL glucose >100 mg/dL, add 1.6 mEq to sodium value)
6. Routine use of bicarbonate, which is not recommended and may be harmful