Management of Diabetic Ketoacidosis (DKA)
The management of diabetic ketoacidosis requires aggressive fluid resuscitation, insulin therapy, electrolyte replacement, and identification and treatment of underlying causes, following a structured protocol that includes hourly monitoring of vital signs, neurological status, blood glucose, and fluid input/output. 1
Diagnosis and Classification
DKA is diagnosed based on:
- Blood glucose >250 mg/dL (although 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 |
Treatment Protocol
1. Fluid Therapy
- Initial fluid resuscitation with isotonic saline at 15-20 ml/kg/hour for the first hour 1
- Continue with balanced crystalloids (e.g., Lactated Ringer's solution) at 4-14 ml/kg/hour based on hydration status 1
- Monitor corrected sodium levels using formula: Measured sodium + 1.6 × [(glucose mg/dl - 100)/100] 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
- Continue insulin infusion until resolution of metabolic acidosis 1
- For patients with uncomplicated DKA, subcutaneous rapid-acting insulin analogs may be used in emergency departments or step-down units 2
3. Electrolyte Replacement
- Potassium: Begin replacement when serum K+ <5.5 mEq/L and adequate urine output is confirmed 1
- Add 20-30 mEq/L potassium to IV fluids (2/3 KCl and 1/3 KPO4) 1
- Phosphate: Generally included in replacement as KPO4, especially with severe hypophosphatemia 1
- Bicarbonate: Generally not recommended for DKA treatment 2
4. Monitoring
- Hourly: Vital signs, neurological status, blood glucose, fluid input/output 1
- Every 2-4 hours: Electrolytes, BUN, creatinine, venous pH 1
- Monitor for complications: cerebral edema, hypoglycemia, hypokalemia, fluid overload 1
5. Transition from IV to Subcutaneous Insulin
- Administer basal insulin 2-4 hours before discontinuing IV insulin to prevent rebound hyperglycemia 2, 1
- Consider low-dose basal insulin analog in addition to IV insulin to prevent rebound hyperglycemia 1
6. Resolution Criteria
DKA is considered resolved when:
- Glucose levels <200 mg/dL
- Serum bicarbonate ≥18 mEq/L
- Venous pH >7.3 1
Complications and Prevention
Common Complications
- Cerebral edema (rare but potentially fatal, especially in children)
- Hypoglycemia due to excessive insulin treatment
- Hypokalemia (occurs in approximately 50% of cases during treatment)
- Hyperglycemic rebound due to abrupt interruption of IV insulin 1
Prevention Strategies
- Avoid too rapid correction of serum osmolality (not exceeding 3 mOsm/kg/h)
- Limit initial vascular expansion in pediatric patients
- Perform hourly glucose monitoring during insulin infusion 1
Discharge Planning and Follow-up
- Identify and treat underlying causes of DKA (infection, missed insulin, new diabetes diagnosis) 1
- Provide education on diabetes self-management, glucose monitoring, and when to seek medical attention 1
- Review medication regimen, especially insulin administration 1
- Schedule follow-up appointment prior to discharge 1
- Include education on sick-day management and the importance of never suspending insulin 1
Special Considerations
- Euglycemic DKA should be treated with the same principles as classic DKA, with the addition of dextrose-containing fluids to prevent hypoglycemia 1
- SGLT2 inhibitors should be discontinued 3-4 days before surgery to prevent DKA 2
- Alternative protocols may be considered in resource-limited settings, but the core principles of fluid resuscitation, insulin therapy, and electrolyte management remain essential 3