Blood Glucose Target for Diabetic Ketoacidosis (DKA) Treatment
DKA treatment should target blood glucose <200 mg/dL, along with serum bicarbonate ≥18 mEq/L and venous pH >7.3 for resolution of the condition. 1
Diagnostic Criteria for DKA
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
The severity of DKA can be classified as:
| 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 Approach
Insulin Therapy
- Continuous IV insulin infusion without an initial bolus at 0.1 units/kg/hour is recommended to avoid rapid glucose reduction and cerebral edema 1
- For patients with complications like chronic kidney disease and heart failure, a reduced rate of 0.05 units/kg/hour is recommended 1
- Target glucose reduction rate should be 50-70 mg/dL/hour 1
Blood Glucose Monitoring and Management
- Monitor blood glucose hourly along with vital signs, neurological status, and fluid input/output 1
- When blood glucose reaches approximately 200 mg/dL, consider adding dextrose to IV fluids to prevent hypoglycemia while continuing insulin therapy to clear ketones 1
- Continue insulin therapy until DKA is resolved (glucose <200 mg/dL, bicarbonate ≥18 mEq/L, and venous pH >7.3) 1
Special Considerations
Euglycemic DKA
- Some patients may present with euglycemic DKA (blood glucose <200 mg/dL with ketoacidosis) 2
- Common causes include recent insulin use, decreased caloric intake, alcohol consumption, pregnancy, and use of SGLT2 inhibitors 2
- These patients still require insulin therapy despite lower glucose levels
Potential Complications to Watch For
- Cerebral edema (rare but potentially fatal, especially in children) 1
- Hypoglycemia from excessive insulin 1
- Hypokalemia during treatment 1
- Fluid overload 1
Prevention of Complications
- Avoid too rapid correction of serum osmolality (not exceeding 3 mOsm/kg/h) 1
- Limit initial vascular expansion in pediatric patients 1
- When blood glucose approaches 200 mg/dL, add dextrose to IV fluids while continuing insulin to clear ketones 1
Alternative Treatment Approaches
For uncomplicated DKA, subcutaneous rapid-acting insulin analogs may be used in emergency departments or step-down units 1, with studies showing comparable efficacy to IV insulin in resolution of hyperglycemia and ketoacidosis 3.