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

Standard Protocol for Managing Diabetic Ketoacidosis (DKA)

The standard protocol for managing DKA requires aggressive fluid resuscitation, insulin therapy, electrolyte replacement, and monitoring until resolution criteria are met (glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3). 1, 2

Initial Assessment and Diagnostic Criteria

• DKA diagnostic criteria: blood glucose >250 mg/dL, venous pH <7.3, bicarbonate <15 mEq/L, and moderate ketonemia or ketonuria 1
• Obtain STAT labs: arterial blood gases, complete blood count with differential, urinalysis, plasma glucose, BUN, electrolytes, chemistry profile, creatinine, and ECG 1
• Obtain chest X-ray and cultures as clinically indicated 1
• Correct serum sodium for hyperglycemia (add 1.6 mEq to sodium value for each 100 mg/dL glucose >100 mg/dL) 1

Fluid Resuscitation

• Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour for the first hour 3
• Continue fluid replacement to restore circulatory volume and tissue perfusion 3
• After initial resuscitation, adjust fluid rate based on hemodynamic status, electrolyte levels, and urine output 1
• Monitor for signs of fluid overload, which can lead to cerebral edema 1

Insulin Therapy

• For moderate to severe DKA: Start continuous IV regular insulin infusion 1
  • Adult patients: IV bolus of regular insulin at 0.15 units/kg followed by continuous infusion at 0.1 unit/kg/hour (typically 5-7 units/hour) 1
  • Pediatric patients: No initial bolus; start continuous infusion at 0.1 unit/kg/hour 1
• If plasma glucose does not fall by 50 mg/dL in the first hour, check hydration status; if acceptable, double insulin infusion rate hourly until glucose decline of 50-75 mg/dL per hour is achieved 1
• When glucose falls below 200 mg/dL, add dextrose (5-10%) to IV fluids and decrease insulin infusion to 0.05-0.1 unit/kg/hour (3-6 units/hour) to maintain glucose between 150-200 mg/dL until acidosis resolves 1

For Mild DKA Only

• May use subcutaneous insulin instead of IV infusion 1, 4
• Give "priming" dose of regular insulin 0.4-0.6 units/kg (half as IV bolus, half as subcutaneous injection) 1
• Follow with subcutaneous regular insulin 0.1 unit/kg/hour every 1-2 hours 1 or every 4 hours 4

Electrolyte Management

• Potassium: Despite total body potassium depletion, mild to moderate hyperkalemia is common 1
  • Begin potassium replacement when serum levels fall below 5.5 mEq/L, assuming adequate urine output 1
  • Add 20-30 mEq potassium (2/3 KCl and 1/3 KPO₄) per liter of infusion fluid to maintain serum potassium 4-5 mEq/L 1
  • If initial potassium is <3.3 mEq/L, start potassium replacement before insulin therapy to prevent arrhythmias 1
• Bicarbonate: Generally not recommended as it makes no difference in resolution of acidosis or time to discharge 1, 3

Monitoring During Treatment

• Check blood glucose every 1-2 hours until stable 1
• Monitor serum electrolytes, glucose, BUN, creatinine, osmolality, and venous pH every 2-4 hours 1, 2
• Follow venous pH (typically 0.03 units lower than arterial pH) and anion gap to monitor acidosis resolution 1, 2
• Direct measurement of β-hydroxybutyrate in blood is preferred for monitoring DKA 1, 2
• Do not use nitroprusside method (urine ketones) to monitor treatment response as it only measures acetoacetic acid and acetone, not β-hydroxybutyrate 1, 2

Resolution Criteria and Transition to Subcutaneous Insulin

• DKA resolution criteria: glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L 2
• Once DKA resolves:
  • If patient is NPO: Continue IV insulin and fluids; supplement with subcutaneous regular insulin as needed every 4 hours (5-unit increments for every 50 mg/dL increase in blood glucose above 150 mg/dL) 1, 2
  • When patient can eat: Start multiple-dose insulin regimen with combination of short/rapid-acting and intermediate/long-acting insulin 1, 2
  • Administer basal insulin 2-4 hours before stopping IV insulin to prevent recurrence of ketoacidosis 1, 2
  • Continue IV insulin infusion for 1-2 hours after starting subcutaneous insulin 2

Complications to Monitor and Prevent

• Cerebral edema: Monitor for headache, altered mental status, seizures, particularly in pediatric patients 1
• Hypoglycemia: Monitor glucose frequently and adjust insulin/dextrose accordingly 5
• Hypokalemia: Monitor potassium levels and replace as needed 1
• Recurrent DKA: Ensure adequate transition to subcutaneous insulin 2

Treatment of Precipitating Factors

• Identify and treat underlying causes (infection, myocardial infarction, stroke, etc.) 1
• Continue monitoring and treatment of concurrent conditions 1

Discharge Planning

• Begin discharge planning at admission 1
• Ensure structured transition of care with clear communication to outpatient providers 1
• Schedule follow-up appointments prior to discharge 1
• Provide education on sick-day management and ketone monitoring 1