2024 ADA Guidelines for Resolution of Diabetic Ketoacidosis (DKA)
According to the 2024 American Diabetes Association guidelines, DKA is considered resolved when blood glucose is less than 200 mg/dL, serum bicarbonate is greater than or equal to 18 mEq/L, and venous pH is greater than 7.3. 1
Diagnostic Criteria for DKA
DKA is defined by 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 |
Management Protocol for DKA Resolution
1. Initial Fluid Resuscitation
- Infuse isotonic saline (0.9% NaCl) at 15-20 ml/kg/h to expand intravascular volume and restore renal perfusion 1
- Goal: Correct estimated fluid deficits (typically 6 liters) within 24 hours
- Replace 50% of estimated fluid deficit in first 8-12 hours 1
- Important consideration: Recent evidence suggests balanced electrolyte solutions (BES) may resolve DKA faster than 0.9% saline, with a mean difference of 5.36 fewer hours to resolution 2, 3
2. Ongoing Fluid Management
- For patients with normal/elevated corrected serum sodium: Switch to 0.45% NaCl
- For patients with low corrected serum sodium: Continue with 0.9% NaCl 1
- Exercise caution in patients with cardiac or renal compromise
3. Potassium Replacement
- Once renal function is confirmed, add 20-30 mEq/L potassium (2/3 KCl and 1/3 KPO₄) to IV fluids
- Avoid hypokalemia (K⁺ <3.3 mEq/L) 1
4. Insulin Therapy
- Exclude hypokalemia before starting insulin
- Initial IV bolus: Regular insulin at 0.15 U/kg body weight
- Continuous infusion: 0.1 U/kg/h (approximately 5-7 U/h in adults) 1
5. Bicarbonate Administration
- Only administer when arterial pH is below 6.9
- Do not administer when pH is 7.0 or higher
- For pH < 6.9: Administer 100 mmol sodium bicarbonate diluted in 400 ml sterile water at 200 ml/h 1
6. Monitoring for Resolution
- Hourly monitoring: Vital signs, neurological status, blood glucose, fluid input/output
- Every 2-4 hours: Electrolytes, BUN, creatinine, venous pH 1
Resolution Criteria
DKA is considered resolved when ALL of the following criteria are met:
- Blood glucose <200 mg/dL
- Serum bicarbonate ≥18 mEq/L
- Venous pH >7.3 1
Post-Resolution Management
Once DKA is resolved:
- Transition from IV insulin to subcutaneous insulin
- Ensure proper discharge planning with education on DKA prevention
- Schedule outpatient follow-up within 1 month of discharge (or within 1-2 weeks if glycemic management medications were changed) 1
Special Considerations
- Euglycemic DKA: Characterized by metabolic acidosis and ketosis with blood glucose <200 mg/dL; requires same treatment approach 1
- SGLT2 inhibitors: Increase risk of euglycemic DKA, particularly with low-carbohydrate diets, fasting, dehydration 1
- Pregnancy: Higher risk of euglycemic DKA due to altered metabolism and increased insulin resistance 1
- Cardiovascular disease: Requires cardiac monitoring during treatment 1
Common Pitfalls to Avoid
- Failure to recognize euglycemic DKA: Don't rule out DKA based solely on normal glucose levels
- Inadequate fluid resuscitation: Underestimating fluid deficits can delay resolution
- Premature discontinuation of IV insulin: Continue until resolution criteria are met
- Neglecting potassium monitoring: Hypokalemia can lead to cardiac arrhythmias
- Overuse of bicarbonate: Only indicated for severe acidosis (pH <6.9)