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

Diabetic Ketoacidosis (DKA) Management Protocol

The management of diabetic ketoacidosis requires a structured approach focusing on fluid resuscitation, insulin therapy, electrolyte correction, and identifying/treating the underlying cause to reduce morbidity and mortality. 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 2
• Identify and treat any precipitating causes such as infection, myocardial infarction, or stroke 1
• Establish IV access and begin continuous cardiac monitoring 3

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 based on hydration status, serum electrolyte levels, and urine output 4
• Consider balanced electrolyte solutions after initial resuscitation to prevent hyperchloremic metabolic acidosis 5

Insulin Therapy

• For critically ill or mentally obtunded patients, administer continuous intravenous insulin as the standard of care 1
• For mild to moderate uncomplicated DKA, subcutaneous rapid-acting insulin analogs may be used in the emergency department or step-down units 1
• Monitor blood glucose every 1-2 hours and adjust insulin accordingly 2
• When transitioning from IV to subcutaneous insulin, administer basal insulin 2-4 hours before stopping the IV insulin to prevent recurrence of ketoacidosis and rebound hyperglycemia 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 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 6
• Monitor and replace magnesium and calcium levels as needed 4
• Bicarbonate administration is generally not recommended as studies have shown it makes no difference in resolution of acidosis or time to discharge 1, 2

Monitoring During Treatment

• Check blood glucose every 1-2 hours until stable 2
• Monitor serum electrolytes, glucose, blood urea nitrogen, creatinine, and osmolality every 2-4 hours 6
• Follow venous pH and anion gap every 2-4 hours to monitor resolution of acidosis 4
• Direct measurement of β-hydroxybutyrate in blood is preferred for monitoring ketoacidosis resolution 4, 2

Resolution Criteria

• Treatment success is indicated by resolution of acidosis (pH >7.3), serum bicarbonate ≥18 mEq/L, and anion gap ≤12 mEq/L 4, 2
• Clinical improvement including mental status, vital signs, and hydration 7

Special Considerations

• For euglycemic DKA (often seen with SGLT2 inhibitor use), ensure adequate carbohydrate administration alongside insulin to prevent perpetuating ketosis 2
• For patients with renal disease, adjust fluid and electrolyte management carefully 3
• For pregnant patients, more aggressive monitoring and treatment may be required 8

Discharge Planning

• Create a structured discharge plan tailored to the individual patient 1
• Provide education on diabetes management, including self-monitoring of blood glucose, when to call the provider, and sick-day management 1
• Schedule follow-up appointments prior to discharge to increase attendance likelihood 6
• Ensure patients have appropriate medications, supplies, and prescriptions at discharge 1

Common Pitfalls to Avoid

• Inadequate fluid resuscitation worsening DKA 2
• Premature discontinuation of insulin therapy before complete resolution of ketosis 2
• Failure to monitor and replace electrolytes leading to complications 2
• Not identifying and treating the underlying precipitating cause 1
• Stopping IV insulin without overlapping with subcutaneous insulin administration 1