Latest Guidelines for Managing Diabetic Ketoacidosis (DKA)
The latest guidelines for managing DKA recommend aggressive fluid resuscitation with balanced crystalloid solutions, continuous IV insulin without an initial bolus at 0.1 units/kg/hour (or 0.05 units/kg/hour in patients with CKD or heart failure), careful electrolyte monitoring and replacement, and treatment of underlying precipitating factors. 1
Diagnostic Criteria
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
DKA 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 |
Initial Management
Fluid Therapy
- Begin with isotonic saline at 15-20 ml/kg/hour for the first hour
- Switch to 0.45% saline at 4-14 ml/kg/hour based on corrected sodium levels
- Balanced crystalloid solutions are preferred over normal saline for maintenance fluid therapy 1, 2
- Calculate corrected sodium using: Measured sodium + 1.6 × [(glucose mg/dl - 100)/100] 1
Insulin Therapy
- Administer continuous IV insulin without an initial bolus at 0.1 units/kg/hour (regular insulin) 1
- For patients with CKD and heart failure, use reduced rate of 0.05 units/kg/hour 1
- Target glucose reduction rate of 50-70 mg/dL/hour 1
- For uncomplicated DKA, subcutaneous rapid-acting insulin analogs may be used in emergency departments or step-down units 3, 1
- Transition to subcutaneous insulin requires administration of basal insulin 2-4 hours before stopping IV insulin to prevent recurrence of ketoacidosis 3
Electrolyte Management
- Monitor potassium closely and 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
- Include phosphate replacement (as KPO4) especially with severe hypophosphatemia 1
- Bicarbonate therapy is generally not recommended unless arterial pH is <7.1 1
Monitoring
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 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 first 4 hours for pediatric patients 1
Other Complications
- Hypoglycemia
- Hypokalemia
- Fluid overload 1
Discharge Planning and Follow-up
Before discharge:
- Identify and treat underlying causes of DKA (infection, missed insulin, new diagnosis)
- 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 1
Special Considerations
- For patients with uncomplicated DKA, subcutaneous insulin approach may be safer and more cost-effective than IV insulin 3
- Sodium-glucose cotransporter-2 inhibitors modestly increase the risk of DKA and euglycemic DKA 4
- Balanced electrolyte solutions resolve DKA faster than 0.9% saline (mean difference of 5.36 hours) 2
By following these guidelines, healthcare providers can effectively manage DKA while minimizing complications and improving patient outcomes.