What is the management approach for Diabetic Ketoacidosis (DKA)?

Management of Diabetic Ketoacidosis (DKA)

The management of DKA requires immediate intervention with fluid resuscitation using isotonic saline (15-20 ml/kg/hour initially), insulin therapy (continuous IV insulin at 0.1 units/kg/hour without bolus), electrolyte replacement, and identification of precipitating factors. 1

Diagnosis and 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

DKA is considered resolved when:

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

Treatment Algorithm

1. Fluid Therapy

• Initial: Isotonic saline at 15-20 ml/kg/hour for the first hour 1
• Subsequent: 0.45% saline at 4-14 ml/kg/hour based on corrected sodium levels 1
• Balanced crystalloid solutions are preferred over normal saline for maintenance fluid therapy 1
• Calculate corrected sodium using: 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 1
• For patients with complications (chronic kidney disease, heart failure), use reduced rate of 0.05 units/kg/hour 1
• Target glucose reduction rate: 50-70 mg/dL/hour 1
• For uncomplicated DKA in appropriate settings, subcutaneous rapid-acting insulin analogs may be used 1

3. Electrolyte Management

• Potassium: Begin replacement when serum K+ <5.5 mEq/L 1
  • Add 20-30 mEq/L potassium to IV fluids (2/3 KCl and 1/3 KPO₄) 1
• Phosphate: Include as KPO₄ especially with severe hypophosphatemia 1

4. Monitoring

• Hourly: 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) 1
• Prevention:
  • Avoid rapid correction of serum osmolality (not exceeding 3 mOsm/kg/h) 1
  • Limit initial vascular expansion to 50 ml/kg in first 4 hours for pediatric patients 1

Other Complications

• Hypoglycemia
• Hypokalemia
• Fluid overload 1

Cost-Effective Approaches

While the American Diabetes Association guidelines should be followed, some cost-effective approaches have been documented:

• Limiting unnecessary laboratory tests 2
• Treating most patients outside of ICU settings when appropriate 2
• Using subcutaneous rapid-acting insulin analogs in uncomplicated cases 1, 3

Patient Education and Follow-up

Before discharge:

• Identify and treat underlying causes (infection, missed insulin, new diagnosis) 1
• 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

Key Pitfalls to Avoid

1. Administering insulin bolus - Can lead to rapid glucose reduction and cerebral edema 1
2. Neglecting potassium replacement - Can lead to life-threatening hypokalemia as insulin drives potassium intracellularly 1
3. Overly rapid fluid resuscitation - Especially in children and elderly, can lead to cerebral edema 1
4. Missing euglycemic DKA - Particularly in patients on SGLT2 inhibitors 4
5. Failure to identify and treat precipitating factors - Can lead to recurrence 1, 4

Recent evidence emphasizes the importance of balanced fluid management, careful insulin administration without bolus dosing, and vigilant monitoring to prevent complications while effectively resolving the metabolic derangements of DKA.