Immediate Management of Diabetic Ketoacidosis (DKA)
The immediate management of DKA requires aggressive fluid resuscitation with normal saline, intravenous insulin therapy after confirming adequate potassium levels, and electrolyte replacement, along with identification and treatment of precipitating factors. 1
Initial Assessment and Diagnosis
Classify DKA severity using these criteria 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 Check for signs of DKA 2:
- Fruity breath odor
- Drowsiness
- Flushed face
- Thirst
- Loss of appetite
- Heavy breathing
- Rapid pulse
Step-by-Step Management Protocol
1. Fluid Resuscitation (First Priority)
- Begin with normal saline (0.9% NaCl) at 10-20 mL/kg/hour during the first hour 1
- Do not exceed 50 mL/kg over the first 4 hours 1
- Switch to 0.45% NaCl (half-normal saline) after initial resuscitation 1
- When blood glucose reaches 250-300 mg/dL, switch to 5% dextrose with 0.45% NaCl 1
2. Insulin Therapy
- Critical step: Check serum potassium before starting insulin
- Start continuous intravenous insulin infusion at 0.1 units/kg/hour ONLY after confirming serum potassium is >3.3 mEq/L 1
- Target glucose reduction: 50-75 mg/dL per hour 1
- Continue insulin infusion until DKA resolves (bicarbonate ≥18 mEq/L, venous pH >7.3) 1
3. Potassium Replacement
- Monitor serum potassium every 2-4 hours initially 1
- Replace potassium based on serum levels to maintain K+ between 4-5 mEq/L 1
- Insulin therapy drives potassium intracellularly, potentially causing dangerous hypokalemia 1, 2
4. Monitoring
- Check vital signs hourly: heart rate, blood pressure, respiratory rate, mental status 1
- Laboratory monitoring every 2-4 hours: electrolytes, BUN, creatinine, pH 1
- Calculate corrected sodium: For each 100 mg/dL glucose >100 mg/dL, add 1.6 mEq to sodium value 1
5. Bicarbonate Administration
- Bicarbonate is generally not recommended for routine use in DKA management 1
- Studies have shown that bicarbonate use made no difference in resolution of acidosis or time to discharge 3
6. Transition to Subcutaneous Insulin
- Administer basal insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia 3
- Low-dose basal insulin analog in addition to IV insulin may prevent rebound hyperglycemia 3
Special Considerations
ICU Admission Criteria 1
- Arterial pH <7.00
- Altered mental status (stupor/coma)
- Hemodynamic instability
- Severe hyperosmolarity (>320 mOsm/kg)
Watch for Complications
- Cerebral edema: Occurs in 0.5-0.9% of DKA episodes 1
- Warning signs: headache, decreased mental status, irritability, abnormal pupillary responses, rising blood pressure with decreasing heart rate
- Hypoglycemia: Monitor closely during insulin therapy 2
- Hypokalemia: Can be life-threatening; monitor potassium levels 1, 2
DKA Resolution Criteria 1
- Glucose <200 mg/dL
- Serum bicarbonate ≥18 mEq/L
- Venous pH >7.3
Discharge Planning
- Identify healthcare provider for follow-up diabetes care 3
- Educate on diabetes self-management, glucose monitoring, and when to seek medical attention 3
- Provide clear instructions on medication regimen, especially insulin administration 3
- Schedule follow-up appointment prior to discharge 3
- Educate on recognition, prevention, and management of DKA to prevent recurrence 3
This protocol emphasizes the critical sequence of interventions (fluids first, then insulin) and the importance of potassium monitoring before insulin administration to prevent life-threatening complications.