What are the guidelines for managing diabetic ketoacidosis (DKA)?

Guidelines for Managing Diabetic Ketoacidosis (DKA)

The management of diabetic ketoacidosis requires immediate fluid resuscitation, insulin therapy, electrolyte replacement, and identification of precipitating causes, with balanced electrolyte solutions being preferred over normal saline for faster DKA resolution. 1, 2

Diagnosis and Initial Assessment

• DKA is characterized by hyperglycemia (blood glucose >250 mg/dL), metabolic acidosis (pH <7.3, serum bicarbonate <18 mEq/L, anion gap >10 mEq/L), and elevated serum or urine ketones, though hyperglycemia is now de-emphasized due to increasing incidence of euglycemic DKA 3
• Initial laboratory evaluation should include plasma glucose, blood urea nitrogen, creatinine, serum ketones, electrolytes with calculated anion gap, osmolality, urinalysis, arterial blood gases, complete blood count with differential, and electrocardiogram 1, 3
• Consider additional tests including amylase, lipase, hepatic transaminases, troponin, creatine kinase, blood and urine cultures, and chest radiography to identify precipitating causes 3
• Continuous cardiac monitoring is crucial in severe DKA (pH <7.0, bicarbonate <10 mEq/L) to detect arrhythmias early 4

Fluid Therapy

• Begin with balanced electrolyte solutions (BES) rather than 0.9% saline at a rate of 15-20 mL/kg/h during the first hour to restore circulatory volume and tissue perfusion 5, 2, 6
• BES (such as lactated Ringer's) resolves DKA faster than 0.9% saline with a mean difference of -5.36 hours and results in lower post-resuscitation chloride and sodium levels 2, 6
• Continue fluid replacement to correct estimated deficits within the first 24 hours, with an induced change in serum osmolality not exceeding 3 mOsm/kg/h 5

Insulin Therapy

• Once hypokalemia is excluded, administer an intravenous bolus of regular insulin at 0.15 U/kg body weight, followed by a continuous infusion at 0.1 U/kg/h 5
• If plasma glucose does not fall by 50 mg/dL from the initial value in the first hour, double the insulin infusion every hour until a steady glucose decline between 50-75 mg/h is achieved 5
• Continue insulin infusion until mental status improves and metabolic abnormalities resolve 5
• Transition from intravenous to subcutaneous insulin requires administration of basal insulin 2-4 h before the intravenous insulin is stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia 1

Electrolyte Management

• Monitor potassium levels closely as total body potassium deficits are common (4-6 mEq/kg) despite potentially normal or elevated initial serum levels due to acidosis 5
• Once renal function is assured and serum potassium is known, add 20-40 mEq/L potassium to the infusion when serum levels fall below 5.5 mEq/L 5, 4
• Monitor blood every 2-4 hours for determination of serum electrolytes, glucose, blood urea nitrogen, creatinine, and osmolality 5
• The use of bicarbonate in people with DKA made no difference in the resolution of acidosis or time to discharge, and its use is generally not recommended 1

Monitoring and Ongoing Management

• Monitor fluid input/output, hemodynamic parameters, and clinical examination to assess progress with fluid replacement 5
• Monitor blood glucose at least every 2-4 hours while the patient takes nothing by mouth 1
• Target blood glucose levels of 100-180 mg/dL (5.6-10.0 mmol/L) 1
• Carefully monitor for complications, particularly electrolyte imbalances that can trigger cardiac arrhythmias 4

Identification and Treatment of Precipitating Causes

• Obtain bacterial cultures of urine, blood, and other sites as needed and administer appropriate antibiotics if infection is suspected 5
• Common precipitating factors include infection, medication non-adherence, new-onset diabetes, and sodium-glucose cotransporter-2 (SGLT2) inhibitor use 3
• SGLT2 inhibitors should be discontinued 3-4 days before surgery to prevent DKA 1

Discharge Planning and Prevention

• A structured discharge plan should be tailored to the individual to reduce length of hospital stay and readmission rates 1, 5
• Include education on the recognition, prevention, and management of DKA for all individuals affected by or at high risk for these events to prevent recurrence and readmission 1
• Prevention strategies include identifying diabetes before DKA develops, educating patients to manage high-risk situations, and ensuring uninterrupted access to diabetes therapies 3

Special Considerations

• Cerebral edema, one of the most dire complications of DKA, occurs more commonly in children and adolescents than in adults 7
• In mixed cases of DKA and Hyperglycemic Hyperosmolar Syndrome (HHS), tailor the therapeutic regimen according to the prominent clinical features present 8
• ICU admission is indicated in the management of DKA in the presence of cardiovascular instability, inability to protect the airway, obtundation, acute abdominal signs or symptoms, or if adequate monitoring for intravenous insulin infusion cannot be provided on the floor 8