What are the criteria for resolving diabetic ketoacidosis (DKA)?

Criteria for Resolving Diabetic Ketoacidosis (DKA)

DKA resolution requires a glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, and venous pH >7.3. 1

Core Resolution Parameters

• Glucose level <200 mg/dL 1
• Serum bicarbonate ≥18 mEq/L 1
• Venous pH >7.3 1
• Anion gap ≤12 mEq/L 1

Monitoring During DKA Treatment

• Blood should be drawn every 2-4 hours for determination of:

  • Serum electrolytes 1
  • Glucose 1
  • Blood urea nitrogen 1
  • Creatinine 1
  • Osmolality 1
  • Venous pH (for DKA) 1

• Venous pH (typically 0.03 units lower than arterial pH) and anion gap can be followed to monitor resolution of acidosis 1

• Generally, repeat arterial blood gases are unnecessary once initial assessment is made 1

Ketone Monitoring Considerations

• Ketonemia typically takes longer to clear than hyperglycemia 1
• Direct measurement of β-hydroxybutyrate (β-OHB) in blood is the preferred method for monitoring DKA 1
• The nitroprusside method only measures acetoacetic acid and acetone, not β-OHB (the strongest and most prevalent acid in DKA) 1
• During therapy, β-OHB converts to acetoacetic acid, which may falsely suggest worsening ketosis if using nitroprusside method 1
• Therefore, urinary or serum ketone levels by nitroprusside method should not be used as indicators of treatment response 1

Post-Resolution Management

Once DKA is resolved:

• If patient is NPO (nothing by mouth):

  • Continue intravenous insulin and fluid replacement 1
  • Supplement with subcutaneous regular insulin as needed every 4 hours 1
  • For adult patients, give 5-unit increments for every 50 mg/dL increase in blood glucose above 150 mg/dL (up to 20 units for blood glucose of 300 mg/dL) 1

• When patient is able to eat:

  • Start a multiple-dose schedule using a combination of short/rapid-acting and intermediate/long-acting insulin 1
  • Continue intravenous insulin infusion for 1-2 hours after starting subcutaneous insulin to ensure adequate plasma insulin levels 1
  • Avoid abrupt discontinuation of intravenous insulin as this can lead to poor glycemic control 1

Special Considerations

• Euglycemic DKA: Some patients may present with normal blood glucose levels (<200 mg/dL) but still have ketoacidosis 2, 3

  • Common with SGLT2 inhibitor use, pregnancy, reduced caloric intake, or recent insulin use 3
  • Resolution criteria still focus on normalizing pH and bicarbonate levels even when glucose is already normal 3

• Normal anion gap DKA: Rarely, patients may present with ketoacidosis but normal anion gap 4

  • Resolution should still be monitored using pH and bicarbonate levels 4

• Mixed DKA and HHS (Hyperglycemic Hyperosmolar State): Approximately one-third of patients may have features of both conditions 5

  • Treatment approach remains the same but tailored to prominent clinical features 5
  • Resolution criteria should address both the ketoacidosis and hyperosmolar components 5