What are the steps in managing a patient with diabetic ketoacidosis (DKA)?

Stepwise Management of Diabetic Ketoacidosis (DKA)

Management of DKA requires restoration of circulatory volume and tissue perfusion, resolution of hyperglycemia, correction of electrolyte imbalance and acidosis, while concurrently treating any underlying cause. 1

Initial Assessment and Diagnosis

• 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
• Continuous cardiac monitoring is crucial in severe DKA to detect arrhythmias early 1
• Identify and treat any precipitating cause such as infection, myocardial infarction, stroke, or medication non-adherence 2, 1

Fluid Therapy

• Begin with balanced electrolyte solutions at 15-20 mL/kg/hour during the first hour to restore circulatory volume and tissue perfusion 1
• Continue fluid replacement to correct estimated deficits within the first 24 hours, ensuring the change in serum osmolality does not exceed 3 mOsm/kg/h 1
• Monitor fluid input/output, hemodynamic parameters, and clinical examination to assess progress with fluid replacement 1

Insulin Therapy

• 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 1
• If plasma glucose does not fall by 50 mg/dL from initial value in the first hour, double the insulin infusion every hour until a steady glucose decline between 50-75 mg/h is achieved 1
• Target blood glucose levels of 100-180 mg/dL 1
• Monitor blood glucose at least every 2-4 hours while the patient takes nothing by mouth 2

Electrolyte Management

• Monitor potassium levels closely as total body potassium deficits are common despite potentially normal or elevated initial serum levels due to acidosis 1
• 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 1
• Bicarbonate administration is generally not recommended as studies show it makes no difference in resolution of acidosis or time to discharge 2, 1

Monitoring for Resolution

• Treatment success is indicated by resolution of acidosis (pH >7.3), serum bicarbonate ≥18 mEq/L, anion gap ≤12 mEq/L, and improvement in clinical symptoms 3
• Direct measurement of β-hydroxybutyrate in blood is the preferred method for monitoring DKA resolution 3, 1
• Monitor venous pH and anion gap every 2-4 hours to track resolution of acidosis 3

Transition from IV to Subcutaneous Insulin

• When transitioning to subcutaneous insulin, administer basal insulin 2-4 hours before stopping the intravenous insulin to prevent recurrence of ketoacidosis and rebound hyperglycemia 2, 1
• Administration of a low dose of basal insulin analog in addition to intravenous insulin infusion may prevent rebound hyperglycemia 3

Special Considerations

• For euglycemic DKA (particularly in patients on SGLT2 inhibitors), ensure adequate carbohydrate administration alongside insulin to prevent perpetuation of ketosis 3
• SGLT2 inhibitors must be discontinued 3-4 days before any planned surgery to prevent DKA 2, 1
• For patients with chronic kidney disease or pregnancy, management requires special attention as data are sparse and recommendations are based mainly on small case series and expert opinion 4

Discharge Planning

• A structured discharge plan should be tailored to the individual patient to reduce length of hospital stay and readmission rates 2
• Include education on recognition, prevention, and management of DKA for all individuals affected by or at high risk for these events 1
• Schedule follow-up appointment with a primary care provider or appropriate specialist within 1-2 weeks of discharge 5

Common Pitfalls to Avoid

• Inadequate fluid resuscitation can worsen DKA 3
• Premature discontinuation of insulin therapy before complete resolution of ketosis can lead to recurrence of DKA 3
• Failure to monitor and replace electrolytes can lead to complications including cardiac arrhythmias 3, 1
• Inadequate carbohydrate administration alongside insulin in euglycemic DKA can perpetuate ketosis 3