How to manage the start of Diabetic Ketoacidosis (DKA)?

Management of Diabetic Ketoacidosis (DKA): Initial Approach

The initial management of DKA requires immediate fluid resuscitation with isotonic saline (0.9% NaCl) at 15-20 ml/kg/hr, followed by insulin therapy and electrolyte replacement, with the goal of correcting fluid deficits within 24 hours. 1

Diagnostic Criteria

Before initiating treatment, confirm DKA diagnosis based on:

• Blood glucose >250 mg/dL
• Arterial pH <7.3
• Serum bicarbonate <15 mEq/L
• Moderate ketonemia or ketonuria 1

Severity classification:

• Mild: pH 7.25-7.30, bicarbonate 15-18 mEq/L, alert mental status
• Moderate: pH 7.00-7.24, bicarbonate 10-14 mEq/L, alert/drowsy mental status
• Severe: pH <7.00, bicarbonate <10 mEq/L, stupor/coma 1

Initial Treatment Algorithm

1. Fluid Resuscitation (First Priority)

• Begin with isotonic saline (0.9% NaCl) at 15-20 ml/kg/hr to expand intravascular volume and restore renal perfusion 1
• Typical total body water deficit in DKA is approximately 6 liters
• Goal: Correct estimated fluid deficits within 24 hours 1

2. Potassium Replacement

• Add 20-30 mEq/L potassium (2/3 KCl and 1/3 KPO₄) to IV fluids
• Important caveat: Only start potassium replacement after confirming adequate renal function and if serum potassium is <5.3 mEq/L
• Never initiate insulin therapy if potassium is <3.3 mEq/L due to risk of life-threatening hypokalemia 1

3. Insulin Therapy

• Confirm potassium is >3.3 mEq/L before starting insulin
• Administer IV bolus of regular insulin at 0.15 U/kg body weight
• Follow with continuous infusion at 0.1 U/kg/h (approximately 5-7 U/h in adults) 1
• Do not reduce insulin infusion rate until ketoacidosis resolves, even if glucose normalizes quickly 1, 2

4. Bicarbonate Therapy

• Only recommended when arterial pH is below 6.9
• Not recommended when pH is 7.0 or higher 1
• Excessive bicarbonate can worsen ketosis, hypokalemia, and increase risk of cerebral edema 3

Monitoring During Initial Management

• Hourly: vital signs, neurological status, blood glucose, fluid input/output
• Every 2-4 hours: electrolytes, BUN, creatinine, and venous pH 1
• Watch for signs of cerebral edema, particularly in children and adolescents 3

Resolution Criteria

DKA is considered resolved when:

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

Common Pitfalls to Avoid

1. Failure to identify and treat precipitating causes - Infection is the most common trigger (particularly UTI and pneumonia), followed by insulin omission 2, 4
2. Overly rapid correction of hyperglycemia - Can lead to cerebral edema, especially in children 3
3. Neglecting potassium monitoring - Hypokalemia can lead to life-threatening arrhythmias during insulin treatment 1, 5
4. Premature discontinuation of insulin - Continue insulin until ketoacidosis resolves, even if glucose normalizes 1
5. Overuse of bicarbonate - Can worsen hypokalemia and potentially increase risk of cerebral edema 3

Special Considerations

• Patients with cardiovascular disease require cardiac monitoring during treatment 1
• Pregnant patients may present with euglycemic DKA requiring immediate attention 1
• Patients with mixed DKA and hyperosmolar state may require more aggressive fluid resuscitation 3