What are the steps to manage diabetic ketoacidosis (DKA)?

Management of Diabetic Ketoacidosis (DKA): A Stepwise Approach

The management of diabetic ketoacidosis requires immediate fluid resuscitation, insulin therapy, electrolyte replacement, and identification and treatment of precipitating factors, with resolution defined as blood glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, and venous pH >7.3. 1

Initial Assessment and Diagnosis

• Definition: DKA is characterized by:

  • Blood glucose >250 mg/dL (though euglycemic DKA can occur with glucose <200 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

• Initial Laboratory Evaluation:

  • Electrolytes, BUN, creatinine
  • Venous pH
  • Serum ketones
  • Complete blood count
  • Urinalysis 1, 2

Step 1: Fluid Resuscitation

• Initial Fluid Therapy:

  • Replace 50% of estimated fluid deficit in first 8-12 hours 1
  • Use balanced crystalloids (Ringer's lactate or Plasma-Lyte) rather than normal saline as they lead to faster DKA resolution (median 13.0 vs 16.9 hours) 3
  • For patients with cardiac compromise, administer fluids cautiously 1

• Fluid Administration Rate:

  • Initial bolus: 15-20 mL/kg in first hour (unless cardiovascular compromise present)
  • Subsequent rate: Calculate remaining deficit and administer over 24-48 hours 1

Step 2: Insulin Therapy

• Intravenous Insulin Administration:

  • Initial bolus: 0.1 units/kg (optional)
  • Continuous infusion: Start at 0.1 units/kg/hour 1, 4
  • Titrate to achieve blood glucose reduction of 50-75 mg/dL/hour
  • Continue insulin infusion until DKA resolves (not just until blood glucose normalizes) 1

• When Blood Glucose Falls Below 200-250 mg/dL:

  • Reduce insulin infusion to 0.02-0.05 units/kg/hour
  • Add dextrose (D5W or D10W) to IV fluids 1

Step 3: Electrolyte Replacement

• Potassium Replacement:

  • Check serum potassium before starting insulin
  • If potassium <3.3 mEq/L: Hold insulin, give potassium replacement first
  • If potassium 3.3-5.3 mEq/L: Add 20-30 mEq potassium per liter of IV fluid
  • If potassium >5.3 mEq/L: Hold potassium, check levels frequently 1

• Bicarbonate Therapy:

  • Only administer if arterial pH <6.9:
    • For pH <6.9: 100 mmol sodium bicarbonate in 400 mL sterile water at 200 mL/h
    • For pH 6.9-7.0: 50 mmol sodium bicarbonate in 200 mL sterile water at 200 mL/h
    • Do not administer if pH ≥7.0 1

• Phosphate:

  • Routine replacement not recommended
  • Consider if serum phosphate <1.0 mg/dL or if patient develops cardiac dysfunction, anemia, or respiratory depression 1

Step 4: Monitoring

• Hourly Monitoring:

  • Vital signs
  • Neurological status
  • Blood glucose
  • Fluid input/output 1

• Every 2-4 Hours:

  • Electrolytes
  • BUN, creatinine
  • Venous pH 1

Step 5: Transition to Subcutaneous Insulin

• When to Transition:

  • DKA resolution criteria met:
    • Blood glucose <200 mg/dL
    • Serum bicarbonate ≥18 mEq/L
    • Venous pH >7.3 1

• Transition Protocol:

  • Administer subcutaneous insulin 1-2 hours before stopping IV insulin
  • Check blood glucose 2 hours after IV insulin discontinuation
  • Continue monitoring every 3-4 hours for first 24 hours after transition 1, 4

Step 6: Identify and Treat Precipitating Factors

• Common Precipitants:
  • Infection
  • Discontinuation or inadequate insulin
  • New-onset type 1 diabetes
  • Medications affecting carbohydrate metabolism (especially SGLT2 inhibitors)
  • Acute medical events
  • Psychological stress 1

Special Considerations

• Euglycemic DKA:

  • Consider in patients on SGLT2 inhibitors with blood glucose <200 mg/dL
  • Treat with same protocol as hyperglycemic DKA 1, 2

• Pregnancy:

  • Higher risk of euglycemic DKA
  • Requires immediate attention due to risk of feto-maternal harm 1

• Cardiac Disease:

  • Requires cardiac monitoring during treatment 1

• Cerebral Edema Risk:

  • More common in children
  • Warning signs: Headache, altered mental status, seizures, bradycardia
  • Treatment: Reduce fluid rate, consider mannitol or hypertonic saline 5

Discharge Planning

• Education:

  • DKA prevention and management
  • Diabetes self-management
  • Glucose monitoring
  • Sick-day management
  • Proper medication administration 1

• Follow-up:

  • Schedule outpatient follow-up within 1 month of discharge
  • If glycemic management medications were changed, follow up within 1-2 weeks 1

Common Pitfalls to Avoid

1. Stopping insulin when blood glucose normalizes - continue until DKA resolves based on pH and bicarbonate criteria 1

2. Excessive fluid administration - can lead to cerebral edema, especially in children 5

3. Failure to recognize euglycemic DKA - particularly in patients on SGLT2 inhibitors 1, 2

4. Inadequate potassium replacement - can lead to life-threatening arrhythmias 1

5. Overuse of bicarbonate therapy - only indicated for severe acidosis (pH <6.9) 1