Guidelines for Managing Diabetic Ketoacidosis (DKA)
The management of diabetic ketoacidosis requires immediate fluid resuscitation with balanced crystalloid solutions at 15-20 ml/kg/hour for the first hour, followed by insulin therapy at 0.1 units/kg/hour after initial fluid resuscitation, with careful electrolyte monitoring and replacement until resolution criteria are met. 1
Diagnosis and Severity Classification
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 phase: Isotonic saline at 15-20 ml/kg/hour for the first hour 1
- Maintenance phase: Balanced crystalloids (Lactated Ringer's solution) at 4-14 ml/kg/hour based on hydration status 1, 2
- Recent evidence shows balanced electrolyte solutions result in faster DKA resolution than 0.9% saline (mean difference of -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, 3
- Intravenous insulin is standard of care for patients with altered mental status or hemodynamic instability 1
- FDA data shows IV insulin at initial dose of 0.5 U/h, adjusted to maintain blood glucose near normoglycemia (100-160 mg/dL) 3
- When transitioning to subcutaneous insulin, administer basal insulin 2-4 hours before discontinuing IV insulin to prevent rebound hyperglycemia 1
3. Electrolyte Management
Potassium replacement:
Phosphate replacement:
- Generally included as KPO4, especially with severe hypophosphatemia 1
Sodium monitoring:
- Calculate corrected sodium: Measured sodium + 1.6 × [(glucose mg/dl - 100)/100] 1
4. Monitoring Protocol
Hourly monitoring:
- Vital signs
- Neurological status
- Blood glucose
- Fluid input/output 1
Every 2-4 hours:
- Electrolytes
- BUN
- Creatinine
- Venous pH 1
Resolution Criteria and Discharge Planning
DKA is considered resolved when:
- Glucose levels <200 mg/dL
- Serum bicarbonate ≥18 mEq/L
- Venous pH >7.3 1
Prior to discharge:
- Identify and treat underlying causes (infection, missed insulin, new diagnosis)
- Educate on diabetes self-management, glucose monitoring, and when to seek medical attention
- Review medication regimen, especially insulin administration
- Schedule follow-up appointment 1
Complications to Watch For
1. 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
2. Hypoglycemia
- Result of excessive insulin treatment
- Perform glucose monitoring every hour during infusion 1
- Add dextrose to IV fluids when serum glucose falls to 250 mg/dL 4
3. Hypokalemia
- Can lead to fatal cardiac arrhythmias
- Begin replacement when K+ <5.5 mEq/L despite potentially normal initial levels 1, 4
4. Hyperglycemic Rebound
- Due to abrupt interruption of IV insulin
- Administer basal insulin 2-4 hours before discontinuing IV insulin 1
Special Considerations
- Euglycemic DKA: Can occur, especially with sodium-glucose cotransporter-2 inhibitors; don't rule out DKA based solely on glucose levels 5
- Alternative protocols: In resource-limited settings without ICU beds, modified protocols using subcutaneous rapid-acting insulin analogs may be considered, though IV insulin remains standard of care 6
Remember that DKA has maintained a 1-2% mortality rate since the 1970s, emphasizing the importance of prompt recognition and proper management 7.