What is the treatment for diabetic ketoacidosis (DKA)?

Treatment of Diabetic Ketoacidosis (DKA)

The treatment of diabetic ketoacidosis requires immediate intervention with fluid resuscitation, insulin therapy, and electrolyte management, followed by identification and treatment of underlying causes. 1

Initial Management

Fluid Therapy

• Begin with isotonic saline at 15-20 ml/kg/hour for the first hour 1
• Continue with 0.45% saline or balanced crystalloids (Lactated Ringer's) at 4-14 ml/kg/hour based on hydration status 1, 2
• Adjust fluid selection based on corrected sodium levels (Measured sodium + 1.6 × [(glucose mg/dl - 100)/100]) 1
• Avoid excessive fluid resuscitation to reduce risk of cerebral edema, especially in children 1, 2

Insulin Therapy

• Start insulin after initial fluid resuscitation 1
• Administer regular insulin by continuous IV infusion at 0.1 units/kg/hour without an initial bolus 1, 3
• Do not give insulin bolus as this increases risk of cerebral edema 1, 2
• If potassium is <3.3 mEq/L, temporarily delay insulin and first administer potassium chloride to bring levels close to 4 mEq/L 4
• Add dextrose to IV fluids once blood glucose falls below 200-250 mg/dL to prevent hypoglycemia 1, 3

Electrolyte Management

• Begin potassium replacement when serum K+ <5.5 mEq/L and adequate urine output is confirmed 1
• Add 20-30 mEq/L potassium (2/3 KCl and 1/3 KPO₄) to IV fluids 1
• Monitor phosphate levels and replace as needed, especially with severe hypophosphatemia 1
• Consider magnesium replacement if hypomagnesemia is present 2

Monitoring

Frequent Assessment

• Monitor vital signs, neurological status, blood glucose, and fluid input/output hourly 1
• Check electrolytes, BUN, creatinine, and venous pH every 2-4 hours 1
• Calculate anion gap to track resolution of ketoacidosis 1, 5

Complications to Watch For

• Cerebral edema: Monitor for deterioration of consciousness, lethargy, decreased alertness 1
• Hypoglycemia: Check glucose hourly during insulin infusion 1, 3
• Hypokalemia: Most common electrolyte abnormality during treatment (occurs in ~50% of cases) 1, 6
• Fluid overload: Especially in patients with cardiac or renal compromise 1

Special Considerations

Sodium Bicarbonate

• Generally not recommended for routine use 1, 7
• Consider only if pH <7.0 or if patient has hemodynamic instability with severe acidosis 4
• If used, administer as infusion rather than bolus 7

Transition from IV to Subcutaneous Insulin

• Administer basal insulin 2-4 hours before discontinuing IV insulin to prevent rebound hyperglycemia 1
• Consider low-dose basal insulin analog in addition to IV insulin to prevent rebound hyperglycemia 1

Resolution Criteria

• DKA is considered resolved when:
  • Glucose <200 mg/dL
  • Serum bicarbonate ≥18 mEq/L
  • Venous pH >7.3 1

Discharge Planning and Prevention

Before Discharge

• Identify and treat underlying causes (infection, missed insulin, new diagnosis) 1
• Educate patient on diabetes self-management, glucose monitoring, and sick-day management 1
• Schedule follow-up appointment 1

Patient Education

• Never suspend insulin during illness 1, 3
• Recognize early warning signs of DKA (thirst, frequent urination, fatigue, abdominal pain) 3, 5
• Monitor glucose more frequently during illness 1
• Contact healthcare provider early when symptoms develop 1

Common Pitfalls to Avoid

1. Failing to identify and treat precipitating causes (infection, missed insulin doses)
2. Administering insulin bolus, which increases risk of cerebral edema
3. Delaying potassium replacement, which can lead to fatal cardiac arrhythmias
4. Correcting hyperglycemia too rapidly, which can precipitate cerebral edema
5. Discontinuing IV insulin before resolving metabolic acidosis
6. Failing to overlap IV insulin with subcutaneous insulin during transition