Guidelines for Managing Diabetic Ketoacidosis (DKA)
The American Diabetes Association recommends managing DKA with initial fluid resuscitation using normal saline (0.9% NaCl) at 10-20 ml/kg/hr during the first hour, followed by continuous intravenous insulin infusion at 0.1 units/kg/hour after confirming serum potassium is >3.3 mEq/L, with transition to balanced crystalloids for maintenance fluids. 1
Diagnosis and Classification of DKA
DKA severity can be classified using the following criteria:
| 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 |
- When calculating sodium levels, use corrected sodium: For each 100 mg/dL glucose >100 mg/dL, add 1.6 mEq to sodium value 1
Treatment Algorithm
1. Initial Fluid Resuscitation
- Begin with normal saline (0.9% NaCl) at 10-20 ml/kg/hr during the first hour
- Do not exceed 50 ml/kg over the first 4 hours 1
- For hyperglycemic patients, transition to 0.45% NaCl (half-normal saline) after initial resuscitation 1
2. Insulin Therapy
- Start continuous intravenous insulin infusion at 0.1 units/kg/hour ONLY after confirming serum potassium >3.3 mEq/L 1
- Target glucose reduction: 50-75 mg/dL per hour 1
- When blood glucose reaches 250-300 mg/dL, switch to 5% dextrose with 0.45% NaCl to prevent hypoglycemia 1
- Intravenous insulin has been shown to effectively normalize blood glucose levels, with studies showing mean blood glucose reaching 128 ± 18 mg/dL after 6 hours of treatment 2
3. Electrolyte Management
- Monitor serum potassium closely as insulin therapy drives potassium intracellularly 1
- Potassium replacement should be based on serum potassium levels:
- If K+ <3.3 mEq/L: Hold insulin and give potassium replacement until K+ >3.3 mEq/L
- If K+ 3.3-5.2 mEq/L: Add 20-30 mEq potassium to each liter of IV fluid
- If K+ >5.2 mEq/L: Do not add potassium, check levels frequently 1
4. Monitoring
- Check vital signs hourly (heart rate, blood pressure, respiratory rate, mental status) 1
- Monitor laboratory values every 2-4 hours initially:
- Electrolytes
- BUN and creatinine
- Arterial or venous pH 1
- Target decrease in serum osmolality should not exceed 3 mOsm/kg/hour 1
Resolution Criteria for DKA
DKA is considered resolved when:
- Glucose <200 mg/dL
- Serum bicarbonate ≥18 mEq/L
- Venous pH >7.3 1
Special Considerations
ICU Admission Criteria
Patients should be admitted to ICU when they present with:
- Arterial pH <7.00
- Altered mental status (stupor/coma)
- Hemodynamic instability
- Severe associated complications
- Severe hyperosmolarity (>320 mOsm/kg) 1
Cerebral Edema Monitoring
- Occurs in 0.5-0.9% of all DKA episodes, more common in children and adolescents 1, 3
- Warning signs: headache, decreased mental status, irritability, abnormal pupillary responses, rising blood pressure with decreasing heart rate 1
- Risk factors include severity of acidosis, greater hypocapnia, higher blood urea nitrogen concentration at presentation, and treatment with bicarbonate 3
Bicarbonate Administration
Discharge Planning
Prior to discharge, ensure:
- Patient education on diabetes management
- Clear instructions on insulin administration
- Education on self-monitoring of blood glucose
- Guidance on when to seek medical attention
- Follow-up appointment scheduled 1
Prevention of Recurrence
- Patient education focusing on adherence to insulin therapy
- Self-care guidelines during illness
- Improved access to medical providers 4
- Identification and management of precipitating factors (infections, medication non-adherence) 4
- Be aware of increased risk of DKA in patients taking sodium-glucose cotransporter-2 (SGLT2) inhibitors 5, 6
The management of DKA requires aggressive but careful treatment to correct metabolic derangements while avoiding complications such as cerebral edema. Following established protocols with close monitoring of clinical and laboratory parameters is essential for optimal outcomes.