What is the protocol for managing Diabetic Ketoacidosis (DKA)?

From the Guidelines

Diabetic ketoacidosis (DKA) management requires prompt intervention with fluids, insulin, and electrolyte replacement, following the most recent guidelines from 2024 1. The management goals include restoration of circulatory volume and tissue perfusion, resolution of ketoacidosis, and correction of electrolyte imbalance and acidosis.

• Begin with aggressive IV fluid resuscitation using normal saline at 15-20 mL/kg/hr for the first hour (typically 1-2 L), then reduce to 250-500 mL/hr based on hemodynamic status.
• Start IV insulin as a continuous infusion at 0.1 units/kg/hr after the initial fluid bolus, without giving an insulin bolus to avoid increasing hypoglycemia risk.
• Monitor blood glucose hourly, aiming for a decrease of 50-75 mg/dL per hour, and when glucose reaches 200-250 mg/dL, add dextrose to IV fluids (D5 or D10) while continuing insulin to clear ketones.
• Replace potassium when levels are below 5.3 mEq/L and urine output is adequate, targeting 4-5 mEq/L, and address other electrolyte abnormalities, particularly phosphate and magnesium.
• Monitor serum ketones, anion gap, and pH every 2-4 hours until ketoacidosis resolves (pH >7.3, bicarbonate >18 mEq/L, and anion gap normalized).
• Transition to subcutaneous insulin only when the patient is eating and metabolically stable, overlapping IV insulin by 1-2 hours, and consider administering a low dose of basal insulin analog in addition to intravenous insulin infusion to prevent rebound hyperglycemia without increased risk of hypoglycemia 1. Throughout treatment, investigate and address the underlying trigger of DKA, such as infection, medication non-adherence, or new-onset diabetes, and provide individualized treatment based on a careful clinical and laboratory assessment 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. Therefore, it is important that you obtain medical assistance immediately.

The protocol for managing Diabetic Ketoacidosis (DKA) involves:

• Recognizing the symptoms of DKA, such as drowsy feeling, flushed face, thirst, loss of appetite, fruity odor on the breath, heavy breathing, and rapid pulse
• Obtaining medical assistance immediately if symptoms of DKA occur
• Key steps in managing DKA include: + Maintaining blood glucose concentrations near normoglycemia (100 to 160 mg/dL) + Administering insulin, such as intravenous Humulin R U-100, to maintain blood glucose concentrations near normoglycemia + Monitoring blood glucose levels frequently to adjust insulin doses as needed + Treating any underlying conditions that may have contributed to the development of DKA, such as infection or dehydration + Providing supportive care, such as fluids and electrolytes, to manage symptoms and prevent complications [2] [3]

From the Research

Protocol for Managing Diabetic Ketoacidosis (DKA)

The management of DKA requires a comprehensive approach, including:

• Reversing metabolic derangements, correcting volume depletion, electrolyte imbalances, and acidosis while concurrently treating the precipitating illness 4
• Hospitalization for aggressive intravenous fluids, insulin therapy, electrolyte replacement, and identification and treatment of the underlying precipitating event along with frequent monitoring of patient's clinical and laboratory states 5
• Initial rehydration using isotonic saline, followed by potassium replacement and low-dose insulin therapy 6
• Continuous follow-up of patients using treatment algorithms and flow sheets to minimize adverse outcomes 6

Key Components of DKA Management

• Fluid resuscitation: Isotonic normal saline remains the standard for initial fluid resuscitation, though balanced solutions have been shown to have faster DKA resolution 7
• Insulin therapy: Current guidelines recommend using continuous IV insulin for DKA management after fluid status has been restored and potassium levels have been achieved 7
• Electrolyte replacement: Regular monitoring is essential for DKA management, as DKA frequently involves multiple electrolyte abnormalities, such as hypokalemia, hypophosphatemia, and hypomagnesemia 7
• Nutrition: Early initiation of oral nutrition has been shown to reduce intensive care unit and overall hospital length of stay 7
• Airway management: For impending respiratory failure, intubation and mechanical ventilation, with monitoring and management of acid-base and fluid status, are recommended 7

Special Considerations

• Cerebral edema: Rapid overcorrection of hyperglycemia with fluids and insulin can lead to cerebral edema, seizures, and death, and clinicians should be aware of risk factors and preventive strategies for cerebral edema 7
• Sodium bicarbonate: The use of sodium bicarbonate is discouraged due to the potential for worsening ketosis, hypokalemia, and risk of cerebral edema, but may be considered in certain situations, such as serum pH below 6.9 or serum bicarbonate levels below 10 mEq/L 7
• Patient factors and comorbidities: Special patient factors and comorbidities, such as pregnancy, renal disease, congestive heart failure, acute coronary syndrome, older age, and use of sodium-glucose cotransporter-2 (SGLT2) inhibitors, should receive more careful attention and consideration, and may require tailored management strategies 4