What is the treatment protocol for hyperglycemia with Diabetic Ketoacidosis (DKA)?

Treatment Protocol for Hyperglycemia with Diabetic Ketoacidosis (DKA)

The treatment of diabetic ketoacidosis requires aggressive fluid resuscitation with isotonic saline (15-20 ml/kg/hour initially), followed by insulin therapy (0.1 units/kg/hour continuous IV infusion without bolus), and careful electrolyte management, particularly potassium replacement when serum K+ falls below 5.5 mEq/L. 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

Treatment Algorithm

1. Fluid Therapy

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

2. Insulin Therapy

• Start continuous IV regular insulin at 0.1 units/kg/hour without an initial bolus 1, 2
• Target glucose reduction rate: 50-70 mg/dL/hour 1
• For patients with chronic kidney disease and heart failure: Consider reduced rate of 0.05 units/kg/hour 1
• Alternative for uncomplicated DKA in appropriate settings: Subcutaneous rapid-acting insulin analogs 1

3. Electrolyte Management

• Potassium: Begin replacement when serum K+ <5.5 mEq/L
  • 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

Monitoring Protocol

• Hourly monitoring:

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

• Every 2-4 hours monitoring:

  • Electrolytes
  • BUN
  • Creatinine
  • Venous pH 1

Resolution Criteria

DKA is considered resolved when:

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

Complications to Watch For

• Cerebral edema: Rare but potentially fatal, especially in children (0.7-1.0%)
  • Prevention: Avoid too rapid correction of serum osmolality (not exceeding 3 mOsm/kg/h) 1
  • For pediatric patients: Limit initial vascular expansion to 50 ml/kg in first 4 hours 1
• Hypoglycemia: Monitor closely during insulin therapy
• Hypokalemia: Can develop rapidly with insulin therapy
• Fluid overload: Particularly in patients with cardiac or renal compromise 1

Common Pitfalls to Avoid

• Premature termination of IV insulin therapy before resolution of ketosis 3
• Insufficient timing or dosing of subcutaneous insulin before discontinuation of IV insulin 3
• Inadequate fluid replacement
• Failure to identify and treat the precipitating cause of DKA 1
• Overly rapid correction of hyperglycemia, which can lead to cerebral edema 1

Transition to Subcutaneous Insulin

• Begin subcutaneous insulin before discontinuing IV insulin to prevent recurrence of hyperglycemia and ketosis
• Overlap IV and subcutaneous insulin administration by 1-2 hours 1
• For patients with established diabetes: Resume previous insulin regimen if effective
• For new-onset diabetes: Calculate total daily dose based on weight (typically 0.5-0.8 units/kg/day) 1

Pre-Discharge Requirements

• Identification and treatment of precipitating factors (infection, missed insulin, etc.)
• Patient education on:
  • Diabetes self-management
  • Blood glucose monitoring
  • Sick-day management
  • When to seek medical attention
  • Proper medication administration 1
• Schedule follow-up appointment 1

This protocol emphasizes the importance of aggressive initial fluid resuscitation followed by careful insulin and electrolyte management, with close monitoring to prevent complications and ensure complete resolution of the metabolic derangements of DKA.