What are the Harrison guidelines for managing Diabetic Ketoacidosis (DKA)?

Harrison Guidelines for Managing Diabetic Ketoacidosis (DKA)

The management of DKA requires immediate fluid resuscitation with isotonic saline (15-20 ml/kg/hour for the first hour), followed by insulin therapy (0.1 units/kg/hour continuous IV infusion without initial bolus), electrolyte replacement (especially potassium when <5.5 mEq/L), and treatment of underlying causes, with close monitoring of vital signs, neurological status, and laboratory parameters. 1

Diagnostic Criteria for DKA

DKA is diagnosed based on the following criteria as defined by the American Diabetes Association:

• 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

• Initial fluid resuscitation: Isotonic saline at 15-20 ml/kg/hour for the first hour
• Subsequent fluid therapy: 0.45% saline at 4-14 ml/kg/hour based on corrected sodium levels
• Balanced crystalloid solutions 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
• Target glucose reduction rate: 50-70 mg/dL/hour
• For patients with chronic kidney disease and heart failure: Reduced rate of 0.05 units/kg/hour 1
• Alternative for uncomplicated DKA: Subcutaneous rapid-acting insulin analogs in emergency departments 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: Include in replacement as KPO₄, especially with severe hypophosphatemia 1
• Bicarbonate: Generally contraindicated 2

4. Monitoring

• Hourly monitoring:
  • Vital signs
  • Neurological status
  • Blood glucose
  • Fluid input/output 1
• Every 2-4 hours:
  • 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 and Prevention

Cerebral Edema

• Rare but potentially fatal complication (0.7-1.0% in children)
• Prevention strategies:
  • Avoid too rapid correction of serum osmolality (not exceeding 3 mOsm/kg/h)
  • Limit initial vascular expansion to 50 ml/kg in the first 4 hours in pediatric patients 1
  • Administer insulin 1-2 hours after starting fluid therapy 2

Other Complications

• Hypoglycemia
• Hypokalemia
• Fluid overload 1

Patient Education and Follow-up

• Identify and treat underlying causes (infection, missed insulin, new diagnosis)
• Before discharge, 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 prior to discharge 1

Special Considerations

• Pediatric patients require careful attention to fluid management to prevent cerebral edema 2
• Sodium-glucose cotransporter-2 (SGLT2) inhibitors increase risk of euglycemic DKA 3
• Mixed presentations of DKA and Hyperglycemic Hyperosmolar Syndrome (HHS) require tailored management 4