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

Emergency Management of Diabetic Ketoacidosis (DKA)

The emergency management of DKA requires immediate fluid resuscitation with isotonic saline at 15-20 ml/kg/hour for the first hour, followed by balanced crystalloid solutions, insulin therapy after initial fluid resuscitation, and careful electrolyte monitoring and replacement. 1

Diagnostic Criteria

• Blood glucose >250 mg/dL (though euglycemic DKA can occur)
• Arterial pH <7.3
• Bicarbonate <15 mEq/L
• Moderate ketonemia or ketonuria 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 Laboratory Evaluation

• Arterial blood gases
• Complete blood count with differential
• Blood glucose
• BUN, creatinine, electrolytes
• Chemistry profile
• Urinalysis
• ECG 1

Step-by-Step Management Algorithm

1. Fluid Therapy

• Begin with isotonic saline at 15-20 ml/kg/hour for the first hour 1
• Continue with balanced crystalloid solutions (e.g., Lactated Ringer's) at 4-14 ml/kg/hour based on hydration status 1, 2
• Recent evidence suggests balanced electrolyte solutions result in faster DKA resolution compared to normal saline (mean difference -5.36 hours) 2
• Monitor for signs of fluid overload:
  • Increased jugular venous pressure
  • Pulmonary crackles/rales
  • Peripheral edema
  • Decreasing oxygen saturation 1

2. Insulin Therapy

• Start insulin AFTER initial fluid resuscitation 1
• Regular insulin by continuous IV infusion at 0.1 units/kg/hour (no initial bolus) 1
• IV insulin infusion is standard of care for patients with altered mental status or hemodynamic instability 1
• Monitor blood glucose hourly 1
• When transitioning from IV to subcutaneous insulin:
  • Administer basal insulin 2-4 hours before discontinuing IV insulin to prevent rebound hyperglycemia 3, 1

3. Electrolyte Replacement

• Potassium:

  • Begin replacement when serum K+ <5.5 mEq/L and adequate urine output is confirmed
  • Add 20-30 mEq/L potassium to IV fluids (2/3 KCl and 1/3 KPO₄) 1
  • Hypokalemia occurs in approximately 50% of cases during treatment 1

• Phosphate:

  • Generally included as KPO₄, especially with severe hypophosphatemia 1

4. Monitoring

• Hourly:

  • Vital signs
  • Neurological status
  • Blood glucose
  • Fluid input/output 1

• Every 2-4 hours:

  • Electrolytes
  • BUN, creatinine
  • Venous pH 1

Complications to Watch For

Cerebral Edema

• Rare but potentially fatal, especially in children (0.7-1.0%)
• Warning signs: deterioration of consciousness, lethargy, decreased alertness
• Prevention: avoid too rapid correction of serum osmolality (not exceeding 3 mOsm/kg/h) 1

Hypoglycemia

• Result of excessive insulin treatment
• Perform glucose monitoring every hour during insulin infusion 1

Hypokalemia

• Monitor potassium levels closely
• Replace as indicated above 1

Fluid Overload

• Particularly concerning in patients with cardiac or renal disease
• Monitor for signs listed above 1

Resolution Criteria

DKA is considered resolved when:

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

Special Considerations

• Identify and treat underlying causes (infection, missed insulin, new diagnosis) 1
• For patients on SGLT2 inhibitors, be alert for euglycemic DKA 4
• In patients with comorbidities like chronic kidney disease, management may need modification 5

Discharge Planning

• Provide education on:
  • Diabetes self-management
  • Glucose monitoring
  • Sick-day management (never suspending insulin)
  • When to seek medical attention 1
• Schedule follow-up appointment prior to discharge 1

The American Diabetes Association emphasizes that structured discharge planning and education are crucial to prevent recurrence and readmission 3, 1.