Management of Diabetic Ketoacidosis (DKA)
The management of diabetic ketoacidosis requires immediate fluid resuscitation with isotonic saline at 15-20 ml/kg/hr, insulin therapy starting with a 0.15 U/kg bolus followed by 0.1 U/kg/hr continuous infusion, and careful electrolyte replacement, particularly potassium, while addressing the underlying precipitating cause. 1
Diagnostic Criteria
DKA is defined by the American Diabetes Association as:
- 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. Initial Fluid Resuscitation
- Administer isotonic saline (0.9% NaCl) at 15-20 ml/kg/hr to expand intravascular volume and restore renal perfusion 1
- Goal: Correct estimated fluid deficits (typically ~6 liters) within 24 hours 1
- Monitor: Vital signs, neurological status, fluid input/output hourly 1
2. Insulin Therapy
- Before starting insulin: Ensure potassium is not <3.3 mEq/L to avoid dangerous hypokalemia 1
- Initial dose: IV bolus of regular insulin at 0.15 U/kg body weight 1
- Maintenance: Continuous infusion at 0.1 U/kg/hr (approximately 5-7 U/hr in adults) 1
- Target: Decrease glucose by 50-75 mg/dL/hr 1
3. Electrolyte Replacement
- Potassium: Add 20-30 mEq/L potassium (2/3 KCl and 1/3 KPO₄) to IV fluids 1
- If K⁺ <3.3 mEq/L: Administer potassium before insulin
- If K⁺ 3.3-5.2 mEq/L: Add potassium to IV fluids
- If K⁺ >5.2 mEq/L: Hold potassium and check levels frequently
- Bicarbonate: Only administer when arterial pH is <6.9 1, 2
- Not recommended when pH ≥7.0 due to potential adverse effects 1
4. Monitoring
- Hourly: Vital signs, neurological status, blood glucose, fluid input/output 1
- Every 2-4 hours: Electrolytes, BUN, creatinine, venous pH 1
- Continuous cardiac monitoring for patients with cardiovascular disease 1
5. Transition to Subcutaneous Insulin
- When DKA is resolved: Blood glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3 1
- Start subcutaneous insulin 1-2 hours before discontinuing IV insulin to prevent recurrence 1
Special Populations
Pregnancy
- Pregnant patients may present with euglycemic DKA requiring immediate attention due to risk of fetal harm 1, 3
- Lower threshold for diagnosis and more aggressive treatment is warranted 3
Chronic Kidney Disease
- Requires careful fluid and electrolyte management 3, 4
- May need lower rates of fluid resuscitation and more careful potassium monitoring 4
SGLT-2 Inhibitor Use
- Be alert for euglycemic DKA (ketoacidosis with normal or only slightly elevated blood glucose) 3, 4, 5
- Treatment principles remain the same, but dextrose may be needed earlier 4
Complications and Pitfalls
Hypoglycemia
- Common complication during treatment 6
- Monitor glucose frequently and add dextrose to IV fluids when glucose falls below 200-250 mg/dL while continuing insulin infusion 1
Hypokalemia
- Can be life-threatening and may cause cardiac arrhythmias 6
- Ensure adequate potassium replacement and frequent monitoring 1
Cerebral Edema
- More common in pediatric patients but can occur in adults
- Avoid too rapid correction of osmolality and glucose 1
Discharge Planning and Prevention
- Provide education on:
- Diabetes self-management
- Glucose monitoring
- Sick-day management
- Proper medication administration
- When to seek medical attention 1
- Schedule follow-up within 1 month of discharge (or within 1-2 weeks if medications were changed) 1
- Address precipitating factors: infection, medication non-adherence, new diabetes diagnosis 1, 5
Remember that early recognition and aggressive management of DKA are essential to reduce morbidity and mortality. The cornerstone of treatment includes fluid resuscitation, insulin therapy, electrolyte replacement, and addressing the underlying cause.