Management of Diabetic Ketoacidosis (DKA)
The management of diabetic ketoacidosis requires immediate administration of isotonic saline (0.9% NaCl) at 15-20 ml/kg/h during the first hour, followed by balanced crystalloids at 4-14 ml/kg/h, along with continuous intravenous regular insulin at 0.1 U/kg/hour without an initial bolus. 1
Initial Assessment and Diagnosis
DKA is diagnosed by:
- Hyperglycemia (blood glucose >250 mg/dL), though euglycemic DKA can occur, especially with SGLT2 inhibitor use 2
- Metabolic acidosis (pH <7.3, serum bicarbonate <18 mEq/L)
- Elevated serum ketones
- Anion gap >10 mEq/L
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 |
Treatment Algorithm
1. Fluid Replacement
- First hour: Isotonic saline (0.9% NaCl) at 15-20 ml/kg/h 1
- Subsequent hours: Switch to balanced crystalloids (e.g., Lactated Ringer's) at 4-14 ml/kg/h based on hydration status 1
- Add 5% dextrose when glucose reaches 250-300 mg/dL to prevent hypoglycemia and cerebral edema 1
2. Insulin Therapy
- Administer regular insulin as continuous IV infusion at 0.1 U/kg/hour (no initial bolus needed) 1, 3
- Monitor blood glucose hourly during infusion 1
- Continue insulin until DKA resolution (glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3) 1
- Administer basal insulin 2-4 hours before discontinuing IV insulin to prevent hyperglycemic rebound 1
3. Electrolyte Management
- Potassium: Begin replacement when serum K+ <5.5 mEq/L at 20-30 mEq/L (2/3 KCl and 1/3 KPO₄) once renal function is confirmed 1
- Monitor electrolytes every 2-4 hours 1
- Calculate corrected sodium: Measured sodium + 1.6 × [(glucose mg/dl - 100)/100] 1
4. Bicarbonate Therapy
- Generally not recommended routinely
- Consider only in severe acidosis (pH <7.0) with circulatory insufficiency or life-threatening hyperkalemia 4
5. Monitoring
- Vital signs and neurological status: Frequently to detect cerebral edema 1
- Blood glucose: Every hour during insulin infusion 1
- Electrolytes, BUN, creatinine, venous pH: Every 2-4 hours 1
- Monitor for signs of fluid overload: Increased jugular venous pressure, pulmonary crackles, peripheral edema, decreasing oxygen saturation 1
Special Considerations
Cerebral Edema Prevention
- Avoid too rapid correction of serum osmolality (not exceeding 3 mOsm/kg/h) 1
- In pediatric patients, limit initial vascular expansion to 50 ml/kg in first 4 hours 1
- Watch for warning signs: Deterioration of consciousness, lethargy, decreased alertness 1
Special Populations
- Pregnancy, chronic kidney disease, heart failure, and elderly patients require modified approaches with more careful fluid management 5
- SGLT2 inhibitor use increases risk of euglycemic DKA (DKA without significant hyperglycemia) 2
Resolution and Discharge Planning
DKA is considered resolved when:
- Glucose <200 mg/dL
- Serum bicarbonate ≥18 mEq/L
- Venous pH >7.3 1
Before discharge:
- Educate patients on diabetes self-management
- Review medication regimen, especially insulin administration
- Identify healthcare provider for follow-up
- Schedule follow-up appointment 1
Common Pitfalls to Avoid
- Inadequate fluid resuscitation: Underestimating dehydration can delay recovery
- Premature discontinuation of IV insulin: Can lead to recurrence of ketoacidosis
- Neglecting potassium replacement: Hypokalemia occurs in approximately 50% of cases during treatment 1
- Failure to identify and treat precipitating causes: Infection, medication non-adherence, new-onset diabetes
- Missing euglycemic DKA: Especially in patients on SGLT2 inhibitors 2
- Abrupt transition from IV to subcutaneous insulin: Start basal insulin 2-4 hours before stopping IV insulin 1
The American Diabetes Association guidelines provide the most comprehensive and recent evidence-based approach to DKA management, emphasizing the importance of fluid resuscitation, insulin therapy, and careful monitoring to prevent complications.