What is the management of diabetic ketoacidosis (DKA)?

Management of Diabetic Ketoacidosis (DKA)

The management of diabetic ketoacidosis requires immediate administration of intravenous fluids (initially isotonic saline at 15-20 ml/kg/hour), continuous IV insulin infusion without bolus (0.1 units/kg/hour), and careful electrolyte replacement, particularly potassium when levels fall below 5.5 mEq/L. 1

Diagnosis and Assessment

DKA is diagnosed based on:

• 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

• First hour: Isotonic saline at 15-20 ml/kg/hour
• Subsequent hours: 0.45% saline at 4-14 ml/kg/hour based on corrected sodium levels
• Balanced crystalloid solutions are preferred over normal saline for maintenance fluid therapy 1
• Calculate corrected sodium: Measured sodium + 1.6 × [(glucose mg/dl - 100)/100] 1

2. Insulin Therapy

• Start continuous IV insulin infusion at 0.1 units/kg/hour WITHOUT an initial bolus
• Avoid bolus to prevent rapid glucose reduction and cerebral edema
• For uncomplicated DKA, subcutaneous rapid-acting insulin analogs may be used in emergency departments or step-down units 1
• Continue insulin until DKA resolution (glucose <200 mg/dL, bicarbonate ≥18 mEq/L, venous pH >7.3) 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: Include as KPO₄, especially with severe hypophosphatemia 1

Monitoring Protocol

• Hourly monitoring:

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

• Every 2-4 hours:

  • Electrolytes
  • BUN
  • Creatinine
  • Venous pH 1

Complications and Prevention

Cerebral Edema

• Rare but potentially fatal (0.7-1.0% in children)
• Prevention:
  • Avoid too rapid correction of serum osmolality (not exceeding 3 mOsm/kg/h)
  • Limit initial vascular expansion to 50 ml/kg in first 4 hours in pediatric patients 1
  • Avoid rapid overcorrection of hyperglycemia 2

Other Complications

• Hypoglycemia
• Hypokalemia
• Fluid overload 1

Special Populations Considerations

• Chronic kidney disease: Requires careful fluid and electrolyte management 3
• Pregnancy: Limited data, recommendations based on small case series and expert opinion 3
• SGLT2 inhibitor users: Be vigilant for euglycemic DKA 3
• Critically ill patients: Consider balanced IV fluid solutions and early nutritional support 2

Resolution Criteria and Discharge Planning

DKA is considered resolved when:

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

Before discharge:

• Identify and treat underlying causes (infection, missed insulin, new diagnosis)
• Provide education on:
  • Diabetes self-management
  • Blood glucose monitoring
  • When to seek medical attention
  • Sick-day management
  • Proper medication administration 1
• Schedule follow-up appointment 1

Alternative Access in Emergency Situations

When intravenous access cannot be established, particularly in severely dehydrated pediatric patients, intraosseous access can be used for fluid resuscitation and insulin administration 4.