What are the current guidelines for managing diabetic ketoacidosis (DKA)?

Current Guidelines for Managing Diabetic Ketoacidosis (DKA)

The American Diabetes Association recommends managing DKA with continuous IV insulin infusion at 0.1 units/kg/hour without an initial bolus, isotonic saline at 15-20 ml/kg/hour for the first hour followed by 0.45% saline, and close monitoring of electrolytes with potassium replacement when serum K+ <5.5 mEq/L. 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

DKA is considered resolved when:

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

Treatment Algorithm

1. Fluid Therapy

• Initial: Isotonic saline at 15-20 ml/kg/hour for the first hour
• Subsequent: 0.45% saline at 4-14 ml/kg/hour based on corrected sodium levels
• Balanced crystalloid solutions are preferred over normal saline for maintenance 1
• Calculate corrected sodium: Measured sodium + 1.6 × [(glucose mg/dl - 100)/100] 1

2. Insulin Administration

• Start continuous IV insulin infusion at 0.1 units/kg/hour without an initial bolus
• For patients with chronic kidney disease or heart failure, reduce rate to 0.05 units/kg/hour
• Target glucose reduction rate: 50-70 mg/dL/hour 1
• For uncomplicated DKA in appropriate settings, subcutaneous rapid-acting insulin analogs may be used 1

3. Electrolyte Management

• Monitor potassium closely
• 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

4. Monitoring

• Hourly: Vital signs, neurological status, blood glucose, fluid input/output
• Every 2-4 hours: Electrolytes, BUN, creatinine, venous pH 1

5. Transition to Subcutaneous Insulin

• Administer basal insulin 2-4 hours before stopping IV insulin to prevent recurrence 1

Complications and Prevention

Cerebral Edema

• Most common cause of mortality, especially in children 2
• Prevention strategies:
  • Avoid insulin bolus
  • Avoid excessive saline resuscitation
  • Prevent rapid decrease in effective plasma osmolality
  • Limit initial vascular expansion to 50 ml/kg in first 4 hours for pediatric patients 1, 2

Other Complications

• Hypoglycemia
• Hypokalemia (can cause cardiac arrhythmias)
• Fluid overload 1

Special Considerations

1. Sodium bicarbonate administration:

   • Generally not recommended for children with DKA 3
   • In adults, consider for patients with pH <7.20 and bicarbonate <12 mmol/L who are hemodynamically unstable 2

2. Potassium management:

   • In patients with low initial potassium, consider delaying insulin and first administering potassium chloride to bring levels close to 4 mmol/L 2

3. Euglycemic DKA:

   • Increasingly recognized, especially with sodium-glucose cotransporter-2 inhibitors
   • Diagnosis should focus on acidosis and ketosis rather than just hyperglycemia 4

Prevention of Recurrent DKA

• Identify and treat underlying causes (infection, missed insulin, new diagnosis) 1
• 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

Pitfalls to Avoid

1. Administering insulin bolus (increases risk of cerebral edema)
2. Rapid correction of hyperglycemia (aim for 50-70 mg/dL/hour)
3. Neglecting potassium replacement
4. Failing to transition properly from IV to subcutaneous insulin
5. Missing the diagnosis of euglycemic DKA
6. Inadequate monitoring of neurological status for early signs of cerebral edema