Treatment of Diabetic Ketoacidosis (DKA)
The management of diabetic ketoacidosis requires immediate medical attention with a protocol that includes fluid resuscitation, insulin therapy, electrolyte replacement, and identification of precipitating factors. 1
Initial Assessment and Diagnosis
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 Protocol
1. Fluid Replacement
- Initial rehydration with isotonic saline (0.9% sodium chloride) 1, 2
- Replace 50% of estimated fluid deficit in first 8-12 hours 1
- Use caution in patients with cardiac compromise 1
- Recent evidence suggests balanced crystalloids (Ringer's lactate or Plasma-Lyte A) may lead to faster DKA resolution than saline (median time to resolution: 13.0 vs 16.9 hours) 3
2. Insulin Therapy
- Low-dose insulin therapy after initial fluid resuscitation 1, 2
- Continue insulin until resolution of metabolic acidosis 1
- Blood glucose should be checked 2 hours after IV insulin discontinuation 1
- Transition to subcutaneous insulin when DKA resolves (glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3) 1
3. Electrolyte Management
- Potassium replacement is crucial (monitor levels every 2-3 hours initially) 1, 4
- Monitor sodium, chloride, and bicarbonate every 4-6 hours 4
- Phosphate replacement may be necessary in some cases 5
4. Monitoring
- Hourly monitoring of:
- Vital signs
- Neurological status
- Blood glucose
- Fluid input/output 1
- Every 2-4 hours monitoring of:
- Electrolytes
- BUN
- Creatinine
- Venous pH 1
Special Considerations
Euglycemic DKA
- Can occur with blood glucose <200 mg/dL
- More common with SGLT2 inhibitor use
- Requires the same treatment approach despite normal glucose levels 1, 5
High-Risk Populations
- Pregnant women (higher risk of euglycemic DKA) 1
- Patients with cardiovascular disease (require cardiac monitoring) 1
- Children and adolescents (higher risk of cerebral edema) 2
Prevention of DKA
- Patient education on diabetes self-management 1
- Regular glucose monitoring 1
- Sick-day management protocols 1, 2
- Instructions to contact physician early during illness 2
- Proper medication administration 1
- Scheduled outpatient follow-up within 1 month of discharge (or 1-2 weeks if medications were changed) 1
Common Pitfalls to Avoid
- Failure to recognize euglycemic DKA, especially in patients on SGLT2 inhibitors 1, 5
- Overly aggressive fluid resuscitation in patients with cardiac compromise 1
- Inadequate potassium monitoring and replacement, which can lead to dangerous cardiac arrhythmias 1, 4
- Discontinuing insulin too early before metabolic acidosis resolves 1
- Missing the precipitating cause of DKA (infection, medication non-compliance, new-onset diabetes) 1, 2
Most patients with DKA can be effectively managed without ICU admission using standardized protocols with careful monitoring, resulting in safe outcomes and reduced healthcare costs 4.