What is the recommended management approach for a Diabetic Ketoacidosis (DKA) patient in the Intensive Care Unit (ICU)?

Management of Diabetic Ketoacidosis (DKA) in the ICU

The cornerstone of DKA management in the ICU includes aggressive fluid resuscitation, insulin therapy, electrolyte correction, and identification/treatment of underlying causes, with continuous monitoring to guide therapy adjustments. 1

Initial Assessment and Stabilization

• Perform careful clinical and laboratory assessment including plasma glucose, blood urea nitrogen, creatinine, serum ketones, electrolytes with calculated anion gap, osmolality, urinalysis, arterial blood gases, and complete blood count 1
• Identify and treat any underlying cause of DKA such as sepsis, myocardial infarction, or stroke 1
• Management goals include restoration of circulatory volume, tissue perfusion, resolution of hyperglycemia/ketoacidosis, and correction of electrolyte imbalances 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
• Recent evidence suggests balanced electrolyte solutions may offer faster DKA resolution compared to normal saline 2, 3, 4
• Continue fluid replacement based on hemodynamic status, serum electrolyte levels, and urine output 1
• Monitor fluid input/output and clinical examination to assess progress with fluid replacement 1

Insulin Therapy

• In critically ill and mentally obtunded patients with DKA, continuous intravenous insulin is the standard of care 1
• For mild or moderate uncomplicated DKA, subcutaneous rapid-acting insulin analogs may be used when combined with aggressive fluid management 1
• Monitor blood glucose every 2-4 hours while the patient takes nothing by mouth and adjust insulin dosing accordingly 1
• 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
• A low dose of basal insulin analog in addition to intravenous insulin infusion may prevent rebound hyperglycemia without increased risk of hypoglycemia 1

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
• Monitor and replace other electrolytes including phosphate, magnesium, and calcium as needed 1
• Bicarbonate administration is generally not recommended as studies have shown it makes no difference in resolution of acidosis or time to discharge 1

Monitoring for Resolution

• During therapy, blood should be drawn every 2-4 hours to determine serum electrolytes, glucose, blood urea nitrogen, creatinine, and osmolality 1
• 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 1
• Direct measurement of β-hydroxybutyrate in blood is preferred for monitoring DKA resolution 5

Transition from ICU and Discharge Planning

• A structured discharge plan should be tailored to the individual patient to reduce length of hospital stay and readmission rates 1
• Discharge planning should begin at admission and be updated as patient needs change 1
• Schedule follow-up appointments prior to discharge to increase the likelihood that patients will attend 1
• Review key areas of knowledge before discharge including identification of diabetes care provider, blood glucose monitoring, recognition and treatment of hyperglycemia/hypoglycemia, and medication administration 1

Common Pitfalls and Caveats

• Inadequate fluid resuscitation can delay recovery and worsen outcomes 1
• Premature discontinuation of insulin therapy before complete resolution of ketosis can lead to recurrence of DKA 1
• Failure to monitor and replace electrolytes can lead to complications, particularly cardiac arrhythmias 1
• Not identifying or treating the underlying cause of DKA can lead to treatment failure 1
• Be aware of euglycemic DKA, particularly in patients taking SGLT2 inhibitors, where ketoacidosis occurs without marked hyperglycemia 5, 6