What is the management of Diabetic Ketoacidosis (DKA)?

Management of Diabetic Ketoacidosis (DKA)

The management of diabetic ketoacidosis requires immediate intervention with fluid resuscitation, insulin therapy, electrolyte correction, and identification of precipitating factors to prevent morbidity and mortality. 1

Initial Assessment and Diagnosis

• DKA presentations vary widely from euglycemia or mild hyperglycemia with acidosis to severe hyperglycemia, dehydration, and coma, requiring individualized treatment based on clinical and laboratory assessment 1
• Laboratory evaluation should include plasma glucose, blood urea nitrogen, creatinine, serum ketones, electrolytes with calculated anion gap, osmolality, urinalysis, arterial blood gases, and complete blood count 2
• Direct measurement of β-hydroxybutyrate in blood is the preferred method for monitoring DKA 2
• Identify and treat any precipitating factors such as infection, myocardial infarction, or stroke 1

Treatment Algorithm

1. Fluid Resuscitation

• Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour during the first hour to restore circulatory volume and tissue perfusion 1, 2
• Continue fluid replacement to correct dehydration, which is a key component of DKA management 2
• Monitor fluid input/output, hemodynamic parameters, and clinical examination to assess progress with fluid replacement 2

2. Insulin Therapy

• For critically ill and mentally obtunded patients with DKA, continuous intravenous insulin is the standard of care 1
• For mild or moderate DKA in stable patients, subcutaneous rapid-acting insulin analogs combined with aggressive fluid management can be as effective as intravenous insulin 1
• Continue insulin therapy until resolution of ketoacidosis (pH >7.3, serum bicarbonate ≥18 mEq/L, and anion gap ≤12 mEq/L) 2
• When glucose levels fall below 200-250 mg/dL, add dextrose to the hydrating solution while continuing insulin infusion to prevent premature termination of insulin therapy 2

3. Electrolyte Management

• Monitor potassium levels closely, as insulin administration can cause hypokalemia despite potentially normal or elevated initial serum levels due to acidosis 2
• 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 3
• Ensure adequate potassium replacement to maintain serum K+ between 4-5 mmol/L 2
• Bicarbonate administration is generally not recommended for DKA patients as studies have shown it makes no difference in resolution of acidosis or time to discharge 1, 2

4. Monitoring During Treatment

• Blood should be drawn every 2-4 hours to determine serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH 1, 2
• Follow venous pH (typically 0.03 units lower than arterial pH) and anion gap to monitor resolution of acidosis 2
• Target blood glucose levels of 100-180 mg/dL during treatment 3

5. Transition to Subcutaneous Insulin

• When transitioning from intravenous to subcutaneous insulin, administer basal insulin 2-4 hours before stopping the intravenous insulin to prevent recurrence of ketoacidosis and rebound hyperglycemia 1
• Start a multiple-dose schedule using a combination of short/rapid-acting and intermediate/long-acting insulin when the patient is able to eat 2

Resolution Parameters

• DKA resolution requires glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L 2
• Ketonemia typically takes longer to clear than hyperglycemia 2

Special Considerations

Pediatric DKA Management

• Insulin therapy must be initiated for children and adolescents with T2DM who are ketotic or in diabetic ketoacidosis 1
• Insulin should be initiated for pediatric patients with random blood glucose concentrations ≥250 mg/dL or HbA1c >9% 1

Common Pitfalls to Avoid

• Premature termination of insulin therapy before complete resolution of ketosis can lead to recurrence of DKA 2
• Inadequate fluid resuscitation can worsen DKA 2
• Interruption of insulin infusion when glucose levels fall is a common cause of persistent or worsening ketoacidosis 2

Discharge Planning

• A structured discharge plan tailored to the individual should be created to reduce length of hospital stay and readmission rates 1
• Schedule follow-up appointments prior to discharge to increase the likelihood that patients will attend 1, 3
• Include education on the recognition and prevention of DKA, as well as proper insulin management 1
• Transition from the acute care setting presents risks for all patients with diabetes, so discharge planning should begin at admission and be updated as patient needs change 1

Special Populations

• Management may need to be modified for patients with chronic kidney disease, pregnancy, or those taking sodium-glucose cotransporter-2 inhibitors (which can cause euglycemic DKA) 4, 5, 6
• For patients taking SGLT2 inhibitors, clinicians should be aware of the possibility of euglycemic DKA, where ketoacidosis occurs without marked hyperglycemia 6, 7