What is the management approach for diabetic ketoacidosis (DKA)?

Management of Diabetic Ketoacidosis (DKA)

The management of diabetic ketoacidosis requires immediate fluid resuscitation with normal saline or balanced crystalloids, continuous intravenous insulin therapy at 0.1 units/kg/hour, electrolyte replacement (particularly potassium), and identification and treatment of precipitating factors. 1

Diagnosis and Classification

DKA is diagnosed based on:

• Hyperglycemia (glucose >250 mg/dL), although euglycemic DKA can occur
• Metabolic acidosis (pH <7.3, bicarbonate <18 mEq/L)
• Presence of ketones in blood or urine
• Elevated anion gap (>10-12 mEq/L) 1

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 Assessment and Monitoring

Essential laboratory tests:

• Glucose
• Arterial or venous blood gases (pH, bicarbonate)
• Serum electrolytes with anion gap calculation
• Blood or urine ketones
• BUN, creatinine
• Complete blood count
• ECG 1

Monitoring requirements:

• Vital signs hourly
• Laboratory tests every 2-4 hours (electrolytes, BUN, creatinine, venous pH)
• Calculate corrected sodium: For each 100 mg/dL glucose >100 mg/dL, add 1.6 mEq to sodium value 1

Treatment Algorithm

1. Fluid Resuscitation

• Initial fluid: Normal saline (0.9% NaCl) at 10-20 mL/kg/hour for the first hour
• Do not exceed 50 mL/kg in the first 4 hours
• If hyperchloremic, consider balanced crystalloids instead of 0.9% saline 1, 2
• When blood glucose reaches 250-300 mg/dL, switch to 5% dextrose with 0.45% NaCl 1

2. Insulin Therapy

• Start continuous IV infusion of regular insulin at 0.1 units/kg/hour (typically 5-7 units/hour for adults)
• No initial bolus is recommended
• Target glucose reduction: 50-75 mg/dL per hour
• Continue insulin infusion until DKA resolves 1, 3

3. Potassium Replacement

• Begin potassium replacement when serum levels are <5.2 mEq/L and patient is producing urine
• Typical replacement: 20-30 mEq potassium in each liter of IV fluid
• Aim to maintain serum potassium between 4-5 mEq/L 1

4. Bicarbonate Therapy

• Not recommended for routine use in DKA management
• May be considered only in severe acidosis (pH <6.9) or in specific clinical situations 1

5. Transition to Subcutaneous Insulin

• Administer basal insulin 2-4 hours before stopping IV insulin
• Ensure overlap between IV and subcutaneous insulin to prevent rebound hyperglycemia
• Continue IV insulin until subcutaneous insulin takes effect 1

Resolution Criteria

DKA is considered resolved when:

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

Complications and Special Considerations

Cerebral Edema

• 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
• Requires immediate intervention 1

Hypoglycemia

• Monitor closely during insulin therapy
• Early warning symptoms may include sweating, drowsiness, dizziness, tremor, hunger
• Treat promptly with glucose-containing solutions 3

ICU Admission Criteria

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

SGLT-2 Inhibitors

• Be aware of increased risk of DKA, including euglycemic DKA, in patients taking these medications 4

Discharge Planning and Prevention

• Educate patients on diabetes self-management
• Review medication regimen, especially insulin administration
• Identify healthcare provider for follow-up care
• Schedule follow-up appointment prior to discharge
• Educate on sick-day management and when to seek medical attention 1

Common Pitfalls to Avoid

1. Inadequate fluid resuscitation: Underestimating fluid needs can delay recovery
2. Premature discontinuation of IV insulin: Always overlap with subcutaneous insulin
3. Inadequate potassium monitoring: Can lead to life-threatening arrhythmias
4. Failure to identify and treat precipitating factors: Common causes include infection, medication non-adherence, and new-onset diabetes 1, 5
5. Overaggressive fluid correction: Target decrease in serum osmolality should not exceed 3 mOsm/kg/hour to prevent cerebral edema 1

Recent evidence suggests that balanced crystalloids like Sterofundin may be superior to normal saline, with shorter DKA resolution time (13.8 vs 18.1 hours), less total IV fluid requirements, and shorter hospital stays 2.