What is the management approach for diabetic ketoacidosis (DKA)?

Management of Diabetic Ketoacidosis (DKA)

The management of diabetic ketoacidosis requires immediate 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), electrolyte replacement (especially potassium when <5.5 mEq/L), and identification and treatment of precipitating factors. 1

Diagnosis and Classification

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

Note: Recent guidelines acknowledge that euglycemic DKA can occur, particularly in patients taking SGLT-2 inhibitors, so hyperglycemia is not always present 2

Treatment Algorithm

1. Fluid Therapy

• Initial resuscitation: Isotonic saline at 15-20 ml/kg/hour for the first hour 1
• Subsequent fluids: 0.45% saline at 4-14 ml/kg/hour based on corrected sodium levels 1
• Formula for corrected sodium: Measured sodium + 1.6 × [(glucose mg/dl - 100)/100] 1
• Transition to oral fluids: When oral fluids are tolerated, IV fluids can be discontinued 3

2. Insulin Therapy

• Initial therapy: Continuous IV insulin infusion at 0.1 units/kg/hour without an initial bolus 1
• Special populations: Reduced rate of 0.05 units/kg/hour for patients with chronic kidney disease and heart failure 1
• Target glucose reduction rate: 50-70 mg/dL/hour 1
• Alternative approach: Subcutaneous rapid-acting insulin analogs at 0.15 U/kg every 2-3 hours may be used in emergency departments or step-down units 1, 3
• Transition to subcutaneous insulin: When DKA is resolved (glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3) 1

3. Electrolyte Management

• Potassium: Begin replacement when serum K+ <5.5 mEq/L, adding 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
• Bicarbonate: Not routinely recommended unless arterial pH is <7.1 4

4. Monitoring

• Hourly monitoring: Vital signs, neurological status, blood glucose, and fluid input/output 1
• Every 2-4 hours: Electrolytes, BUN, creatinine, and venous pH 1
• Watch for complications: Cerebral edema, hypoglycemia, hypokalemia, and fluid overload 1

Complications and Prevention

Hypoglycemia

• Common symptoms: sweating, drowsiness, dizziness, anxiety, tremor, blurred vision, hunger, slurred speech 5
• Severe symptoms: disorientation, seizures, unconsciousness 5
• Prevention: Regular blood glucose monitoring, especially before activities like driving 5
• Treatment: Oral glucose for mild-moderate cases; glucagon injection or IV glucose for severe cases 5

Cerebral Edema

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

DKA Resolution

DKA is considered resolved when:

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

Identifying and Addressing Precipitating Factors

Common precipitating factors include:

• Infection
• Missed insulin doses
• New diagnosis of diabetes
• Medications (e.g., steroids)
• Acute illness
• Emotional stress 1, 2

Patient Education Before Discharge

Prior to discharge, provide education on:

• Diabetes self-management
• Blood glucose monitoring
• When to seek medical attention (e.g., persistent vomiting, inability to maintain hydration)
• Sick-day management protocols
• Proper medication administration, especially insulin 1

Important caveat: While some older studies suggest managing DKA outside of ICU settings 6, 3, current guidelines recommend intensive monitoring in an emergency ward with experienced staff or in an ICU for optimal outcomes, especially for moderate to severe cases 1.