What are the treatment guidelines for diabetic ketoacidosis (DKA)?

Treatment Guidelines for Diabetic Ketoacidosis (DKA)

The treatment of diabetic ketoacidosis requires immediate medical attention with a structured approach focusing on fluid resuscitation, insulin therapy, electrolyte replacement, and identification of precipitating factors to reduce mortality. 1

Diagnosis Criteria

DKA is diagnosed based on the following criteria:

• Blood glucose >250 mg/dL
• Arterial pH <7.3
• Serum 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 Replacement

• Initial fluid therapy: Replace 50% of estimated fluid deficit in first 8-12 hours 1
• Start with isotonic saline (0.9% NaCl) for extracellular volume repletion
• Use caution with fluid administration in patients with cardiac compromise 1
• After initial volume expansion, switch to 0.45% saline with 5% dextrose once blood glucose falls below 200-250 mg/dL to prevent hypoglycemia 1, 2

2. Insulin Therapy

• Begin with intravenous (IV) insulin infusion
• Continue IV insulin until resolution of DKA (glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3) 1
• Target blood glucose between 150-200 mg/dL until DKA resolves 1
• Administer subcutaneous basal insulin 2-4 hours before discontinuing IV insulin to prevent rebound hyperglycemia 1
• Check blood glucose 2 hours after IV insulin discontinuation 1

3. Electrolyte Management

• Potassium: Monitor levels closely as hypokalemia may occur during treatment 1, 3
  • If initial potassium is low or normal, begin replacement immediately
  • If initial potassium is elevated, delay replacement until urine output is established
• Phosphate: Consider replacement if severe hypophosphatemia develops
• Bicarbonate: Generally not recommended unless pH is extremely low (<6.9) or in cases of severe cardiovascular compromise 1

4. Monitoring

• Hourly monitoring: Vital signs, neurological status, blood glucose, fluid input/output 1
• Every 2-4 hours: Electrolytes, BUN, creatinine, venous pH 1
• Continue frequent monitoring (every 3-4 hours) for the first 24 hours after transition to subcutaneous insulin 1

Special Considerations

Precipitating Factors

Address underlying causes of DKA, which commonly include:

• Infection
• Discontinuation or inadequate insulin
• New-onset type 1 diabetes
• Medications affecting carbohydrate metabolism
• Acute medical events
• Psychological stress and eating disorders 1

Euglycemic DKA

• Be vigilant for euglycemic DKA, particularly in pregnant patients and those taking SGLT2 inhibitors 1, 4
• Treatment principles remain the same, though dextrose administration may be needed earlier

Complications to Monitor

• Cerebral edema: More common in pediatric patients; monitor for headache, altered mental status, or abnormal neurological findings 2, 5
• Hypoglycemia: Common adverse event during treatment; monitor glucose closely 3
• Hyperchloremic metabolic acidosis: May develop during treatment, especially with rapid fluid administration 2
• Hypokalemia: Can develop rapidly during insulin therapy 1, 3

Resolution and Discharge Planning

DKA is considered resolved when:

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

Discharge Considerations

• Provide education on DKA prevention and management
• Schedule outpatient follow-up within 1 month (or 1-2 weeks if medications were changed) 1
• Educate on diabetes self-management, glucose monitoring, sick-day management, and proper medication administration 1
• Consider psychological counseling and social support, especially for patients with recurrent DKA 1

Common Pitfalls to Avoid

• Inadequate fluid resuscitation: Underestimating fluid deficit can delay recovery
• Premature discontinuation of IV insulin: Can lead to recurrence of ketoacidosis
• Failure to overlap IV and subcutaneous insulin: Can cause rebound hyperglycemia 1
• Inadequate potassium replacement: Can lead to life-threatening hypokalemia during treatment 3
• Missing precipitating factors: Always search for and address underlying causes
• Overlooking mental health factors: Psychological issues often contribute to DKA episodes, especially in young patients 1