What is the treatment for resolving diabetic ketoacidosis (DKA)?

Treatment for Resolving Diabetic Ketoacidosis (DKA)

The treatment for resolving diabetic ketoacidosis requires aggressive fluid resuscitation, continuous insulin therapy, electrolyte management, and addressing underlying causes, with resolution defined as glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L. 1, 2

Initial Management

• Begin aggressive fluid resuscitation with isotonic saline (0.9% NaCl) at a rate of 15-20 mL/kg/hour to restore circulatory volume and tissue perfusion 3, 2
• Start continuous intravenous insulin infusion as the standard of care for critically ill and mentally obtunded patients with DKA 1
• Identify and treat any correctable underlying cause of DKA such as sepsis, myocardial infarction, or stroke 1, 3
• Perform careful clinical and laboratory assessment to guide individualized treatment, as DKA presentations can range from mild hyperglycemia to severe dehydration 3, 2

Fluid Management

• After initial volume expansion with isotonic saline, subsequent fluid choice depends on hydration status and electrolyte levels 2
• When serum glucose reaches 250 mg/dL, change fluid to 5% dextrose with 0.45-0.75% NaCl while continuing insulin therapy to resolve ketosis 2
• Continue fluid replacement to correct estimated deficits within the first 24 hours 3

Insulin Therapy

• For critically ill patients, administer continuous intravenous regular insulin at an initial rate of 0.1 units/kg/hour 3, 4
• Continue insulin therapy until resolution of ketoacidosis (pH >7.3, serum bicarbonate ≥18 mEq/L, and anion gap ≤12 mEq/L) regardless of glucose levels 3, 2
• For mild or moderate uncomplicated DKA, subcutaneous rapid-acting insulin analogs combined with aggressive fluid management can be as effective as intravenous insulin 1, 5
• When glucose falls below 200-250 mg/dL, add dextrose to the hydrating solution while continuing insulin infusion to prevent hypoglycemia while resolving ketosis 1, 2

Electrolyte Management

• Monitor potassium levels closely, as insulin administration can cause hypokalemia 3, 2
• Include 20-30 mEq/L potassium (2/3 KCl and 1/3 KPO₄) in the infusion once renal function is assured 6
• Maintain serum potassium between 4-5 mmol/L 3, 2
• Bicarbonate administration is generally not recommended for DKA patients with pH >7.0 1, 7

Monitoring During Treatment

• Draw blood 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 3, 2
• Direct measurement of β-hydroxybutyrate in blood is the preferred method for monitoring DKA 3, 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 1, 2
• Remember that ketonemia typically takes longer to clear than hyperglycemia 3, 2

Transition 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 1
• Recent studies have reported that the administration of a low dose of basal insulin analog in addition to intravenous insulin infusion may prevent rebound hyperglycemia without increased risk of hypoglycemia 1
• When the patient is able to eat, start a multiple-dose schedule using a combination of short/rapid-acting and intermediate/long-acting insulin 3, 2

Common Pitfalls to Avoid

• Premature termination of insulin therapy before complete resolution of ketosis can lead to recurrence of DKA 3, 2
• Interruption of insulin infusion when glucose levels fall is a common cause of persistent or worsening ketoacidosis 3, 2
• Inadequate fluid resuscitation can worsen DKA 3
• Failure to monitor and replace electrolytes can lead to complications 6, 2

Discharge Planning

• Develop a structured discharge plan tailored to the individual patient 1
• Ensure medication reconciliation with cross-checking of home and hospital medications 1
• Schedule follow-up appointments prior to discharge to increase the likelihood of attendance 1
• Transmit discharge summaries to the primary care clinician as soon as possible after discharge 1
• Provide education on diabetes management and sick-day protocols to prevent recurrence 8