What are the treatment complications of Diabetic Ketoacidosis (DKA)?

From the Guidelines

The treatment of Diabetic Ketoacidosis (DKA) is associated with several complications, including hypoglycemia, hypokalemia, and hyperchloremic metabolic acidosis, which can be mitigated with careful fluid and electrolyte management, as well as insulin therapy, as reported in the most recent study 1.

Complications of DKA Treatment

The complications of DKA treatment can be categorized into several key areas, including:

• Hypoglycemia, which can occur due to overzealous insulin therapy, requiring regular blood glucose monitoring and adjustment of insulin infusion rates 1
• Hypokalemia, which can result from insulin administration and treatment of acidosis with bicarbonate, necessitating potassium replacement when levels fall below 5.3 mEq/L 1
• Hyperchloremic metabolic acidosis, which can develop from excessive normal saline administration, and can be mitigated by using balanced crystalloid solutions 1
• Fluid overload, which can lead to pulmonary edema, particularly in patients with cardiac or renal disease, requiring careful fluid administration and monitoring 1

Management of DKA Complications

The management of DKA complications requires a careful balance of fluid resuscitation, electrolyte replacement, and insulin therapy, as well as individualization of treatment based on a careful clinical and laboratory assessment 1.

• The use of basal insulin analogs in addition to intravenous insulin infusion may prevent rebound hyperglycemia without increased risk of hypoglycemia 1
• The administration of subcutaneous rapid-acting insulin analogs may be safer and more cost-effective than treatment with intravenous insulin for individuals with uncomplicated DKA 1
• The use of bicarbonate in people with DKA is generally not recommended, as it has been shown to make no difference in the resolution of acidosis or time to discharge 1

From the FDA Drug Label

Hyperglycemia (too much glucose in the blood) may develop if your body has too little insulin Hyperglycemia can be brought about by any of the following: Omitting your insulin or taking less than your doctor has prescribed. In patients with type 1 or insulin-dependent diabetes, prolonged hyperglycemia can result in DKA (a life-threatening emergency) The first symptoms of DKA usually come on gradually, over a period of hours or days, and include a drowsy feeling, flushed face, thirst, loss of appetite, and fruity odor on the breath. With DKA, blood and urine tests show large amounts of glucose and ketones. Heavy breathing and a rapid pulse are more severe symptoms If uncorrected, prolonged hyperglycemia or DKA can lead to nausea, vomiting, stomach pain, dehydration, loss of consciousness, or death.

The treatment complications of Diabetic Ketoacidosis (DKA) include:

• Nausea
• Vomiting
• Stomach pain
• Dehydration
• Loss of consciousness
• Death 2

From the Research

Treatment Complications of Diabetic Ketoacidosis (DKA)

• The treatment of DKA can be complicated by several factors, including the selection of intravenous (IV) fluids, insulin therapy, and electrolyte replacement 3.
• The use of isotonic normal saline as the initial fluid resuscitation is standard, but balanced solutions have been shown to have faster DKA resolution 3, 4.
• Current guidelines recommend using continuous IV insulin for DKA management after fluid status has been restored and potassium levels have been achieved 3.
• However, the British guidelines recommend using subcutaneous (SQ) insulin glargine along with continuous regular IV insulin, which has shown faster DKA resolution and shorter hospital stays compared to continuous IV insulin alone 3.
• Rapid overcorrection of hyperglycemia with fluids and insulin can lead to cerebral edema (CE), seizures, and death, and clinicians should be aware of risk factors and preventive strategies for CE 3.
• DKA frequently involves multiple electrolyte abnormalities, such as hypokalemia, hypophosphatemia, and hypomagnesemia, and regular monitoring is essential for DKA management 3.
• The use of sodium bicarbonate is discouraged due to the potential for worsening ketosis, hypokalemia, and risk of CE, but it can be considered in certain situations, such as when the serum pH falls below 6.9 or when serum pH is less than 7.2 and/or serum bicarbonate levels are below 10 mEq/L 3.

Comparison of Treatment Protocols

• A study comparing balanced crystalloids with saline for the acute treatment of adults with DKA found that balanced crystalloids resulted in more rapid resolution of DKA 4.
• Another study compared subcutaneous insulin with traditional intravenous insulin infusion in the treatment of mild to moderate DKA and found that subcutaneous insulin may be an effective alternative option with fewer hypoglycemic effects 5.

Diagnostic and Therapeutic Challenges

• Diabetic ketoacidosis represents an acute, severe complication of relative insulin deficiency and a common presentation of Type 1 Diabetes Mellitus (T1DM) primarily and, occasionally, Type 2 Diabetes Mellitus (T2DM) in children and adolescents 6.
• Diagnostic challenges include differentiating between T1DM and T2DM, between DKA and hyperosmolar hyperglycaemic state (HHS), and between DKA and alternative diagnoses presenting with overlapping symptoms 6.
• The mainstays of DKA management include careful fluid resuscitation, timely intravenous insulin administration, restoration of shifting electrolyte disorders, and addressing underlying precipitating factors 6.