What is the management of Diabetic Ketoacidosis (DKA)?

Management of Diabetic Ketoacidosis (DKA)

The management of diabetic ketoacidosis requires immediate fluid resuscitation with isotonic saline at 15-20 ml/kg/hour for the first hour, followed by balanced crystalloids at 4-14 ml/kg/hour, insulin therapy starting at 0.1 units/kg/hour after initial fluid resuscitation (without bolus), and careful electrolyte monitoring and replacement, particularly potassium when levels fall below 5.5 mEq/L. 1

Diagnosis and Severity Assessment

DKA is diagnosed based on the following criteria:

• Blood glucose >250 mg/dL
• 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

Treatment Algorithm

1. Fluid Resuscitation

• Initial: Isotonic saline at 15-20 ml/kg/hour for the first hour 1
• Subsequent: Switch to balanced crystalloids (Lactated Ringer's) at 4-14 ml/kg/hour based on hydration status 1
• Calculate corrected sodium: Measured sodium + 1.6 × [(glucose mg/dl - 100)/100] 1
• Monitor for fluid overload: Check jugular venous pressure, pulmonary crackles, peripheral edema, and oxygen saturation 1

2. Insulin Therapy

• Start insulin 1-2 hours after beginning fluid resuscitation 1, 2
• Regular insulin by continuous IV infusion at 0.1 units/kg/hour (no initial bolus) 1
• Continue until DKA resolves: glucose <200 mg/dL, bicarbonate ≥18 mEq/L, venous pH >7.3 1
• Transition to subcutaneous insulin: Administer basal insulin 2-4 hours before discontinuing IV insulin to prevent rebound hyperglycemia 1

3. Electrolyte Management

• Potassium replacement:
  • Begin 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
• Phosphate replacement:
  • Generally included as KPO4, especially with severe hypophosphatemia 1
• Bicarbonate administration is contraindicated in most cases 2

4. Monitoring Protocol

• Hourly: Vital signs, neurological status, blood glucose, fluid input/output 1
• Every 2-4 hours: Electrolytes, BUN, creatinine, venous pH 1
• Watch for complications: cerebral edema, hypoglycemia, hypokalemia, fluid overload 1

Complications and Prevention

Cerebral Edema

• Rare but potentially fatal (0.7-1.0% in children)
• Warning signs: Deterioration of consciousness, lethargy, decreased alertness
• Prevention: Avoid too rapid correction of serum osmolality (not exceeding 3 mOsm/kg/h) 1
• Treatment: Immediate administration of mannitol or hypertonic saline 1

Hypoglycemia

• Caused by excessive insulin treatment
• Prevention: Hourly glucose monitoring during insulin infusion
• Management: Add glucose to IV fluids when blood glucose falls below 250 mg/dL 1, 3

Hypokalemia

• Occurs in approximately 50% of cases during treatment
• Prevention: Regular monitoring and early replacement when K+ <5.5 mEq/L 1

Hyperglycemic Rebound

• Prevention: Administer basal insulin 2-4 hours before discontinuing IV insulin 1, 3

Special Considerations

Euglycemic DKA

• Increasingly recognized, especially with SGLT2 inhibitor use
• Diagnosis based on acidosis and ketosis even without significant hyperglycemia 4

Patient Education for Prevention

• Sick-day management: Never suspend insulin during illness
• Frequent glucose monitoring during illness
• When to seek medical attention
• Self-monitoring of blood glucose 1

Resolution Criteria

DKA is considered resolved when:

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

Discharge Planning

• Identify and treat underlying causes (infection, missed insulin, new diagnosis)
• Schedule follow-up appointment prior to discharge
• Review medication regimen, especially insulin administration
• Educate on diabetes self-management and when to seek medical attention 1

Common Pitfalls to Avoid

1. Administering insulin bolus (increases risk of cerebral edema)
2. Starting insulin before adequate fluid resuscitation
3. Neglecting potassium monitoring and replacement
4. Using bicarbonate therapy (contraindicated in most cases)
5. Discontinuing IV insulin without prior administration of basal insulin
6. Inadequate monitoring for complications, especially cerebral edema in children

The management approach outlined above reflects current best practices based on American Diabetes Association guidelines, with emphasis on careful fluid management, appropriate insulin therapy, and vigilant monitoring to prevent complications 1.