What is the treatment protocol for a patient with Diabetic Ketoacidosis?

Treatment Protocol for Diabetic Ketoacidosis (DKA)

The treatment of Diabetic Ketoacidosis requires aggressive fluid resuscitation, insulin therapy, and electrolyte management with close monitoring of clinical and laboratory parameters until resolution of acidosis and hyperglycemia. 1

Diagnosis and Classification

DKA is diagnosed when the following criteria are met:

• 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 (0.9% NaCl) at 15-20 ml/kg/hour 1
• Subsequent hours: 0.45% saline at 4-14 ml/kg/hour based on corrected sodium levels
• Formula for corrected sodium: Measured sodium + 1.6 × [(glucose mg/dl - 100)/100] 1
• Total fluid replacement: Typically 2-3 liters of isotonic saline followed by 2-4 L of 5% glucose in 0.45% saline 2
• Balanced crystalloid solutions are preferred over normal saline for maintenance fluid therapy 1

2. Insulin Therapy

• Initial approach: Continuous IV insulin infusion without an initial bolus at 0.1 units/kg/hour using regular insulin 1, 3
• For patients with CKD or heart failure: Reduced rate of 0.05 units/kg/hour with no initial bolus 1
• Target glucose reduction rate: 50-70 mg/dL/hour 1
• Transition to subcutaneous insulin: When DKA is resolved (glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3) 1
• Alternative for uncomplicated DKA: Subcutaneous rapid-acting insulin analogs may be used in emergency departments or step-down units 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
  • Monitor potassium levels every 2-3 hours initially 1
• Phosphate: Include as KPO₄ in replacement fluids, especially with severe hypophosphatemia 1
• Bicarbonate: Generally not recommended, even in severe acidosis (pH <7.0), as it does not improve time to resolution of acidosis or hospital length of stay 4

Monitoring Protocol

Frequent Monitoring (Hourly)

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

Regular Monitoring (Every 2-4 Hours)

• Electrolytes
• BUN and creatinine
• Venous pH 1

Laboratory Parameters for Resolution

DKA is considered resolved when:

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

Potential Complications and Management

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)
• For pediatric patients: Limit initial vascular expansion to 50 ml/kg in the first 4 hours 1

Other Complications

• Hypoglycemia: Monitor glucose closely, especially when starting glucose-containing fluids
• Hypokalemia: Monitor potassium levels and replace as needed
• Fluid overload: Adjust fluid rates in patients with heart or renal failure 1, 3

Special Considerations

Patients with Heart Failure or Renal Disease

• Use reduced insulin infusion rate (0.05 units/kg/hour)
• Monitor fluid status more carefully
• Consider slower fluid administration rates 1, 5

Insulin Interactions

• Insulin requirements may be reduced with:
  • Oral antidiabetic agents
  • Salicylates (e.g., aspirin)
  • Sulfa antibiotics
  • Alcohol
  • Certain antidepressants
  • Some kidney and blood pressure medications 3

Post-Resolution Care

Before Discharge

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

Common Pitfalls to Avoid

1. Excessive fluid administration: Can lead to cerebral edema, especially in children
2. Insulin bolus: Avoid initial bolus to prevent rapid glucose reduction
3. Inadequate potassium monitoring: Can lead to life-threatening hypokalemia during treatment
4. Bicarbonate administration: Generally unnecessary and may not improve outcomes 1, 4
5. Failure to identify precipitating factors: Always look for underlying causes of DKA
6. Premature discontinuation of IV insulin: Continue until acidosis is resolved, not just until blood glucose normalizes 1