What is the management approach for Diabetic Ketoacidosis (DKA)?

Management of Diabetic Ketoacidosis (DKA)

The management of diabetic ketoacidosis requires immediate implementation of a structured protocol focusing on fluid resuscitation, insulin therapy, electrolyte correction, and identification of precipitating causes to reduce mortality and prevent complications. 1

Initial Assessment and Management

• 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
• Management goals include:
  • Restoration of circulatory volume and tissue perfusion
  • Resolution of ketoacidosis
  • Correction of electrolyte imbalance and acidosis
  • Treatment of any underlying cause (sepsis, myocardial infarction, stroke) 1

Fluid Therapy

• Begin with isotonic saline at 15-20 ml/kg/h during the first hour to restore circulatory volume and tissue perfusion 1
• Monitor fluid input/output, hemodynamic parameters, and clinical examination to assess progress with fluid replacement 1
• Total body water deficit in severe cases can be substantial, requiring careful replacement over 24 hours 2

Insulin Therapy

• For critically ill and mentally obtunded patients with DKA, continuous intravenous insulin is the standard of care 1
• Once hypokalemia is excluded, administer intravenous insulin:
  • Initial bolus: 0.15 U/kg body weight of regular insulin
  • Followed by continuous infusion at 0.1 U/kg/h 2
• If plasma glucose does not fall by 50 mg/dl in the first hour, double the insulin infusion rate hourly until achieving a steady glucose decline of 50-75 mg/h 2
• For uncomplicated DKA, subcutaneous rapid-acting insulin analogs may be used in the emergency department or step-down units, which can be safer and more cost-effective than IV insulin 1
• When using subcutaneous insulin, ensure:
  • Adequate fluid replacement
  • Frequent bedside glucose testing
  • Appropriate treatment of concurrent infections
  • Appropriate follow-up to avoid recurrent DKA 1

Transition from IV 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 show that administering a low dose of basal insulin analog in addition to intravenous insulin infusion may prevent rebound hyperglycemia without increased hypoglycemia risk 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 3
• 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, 2
• In patients with relatively low plasma potassium levels, temporarily delay insulin administration and first administer potassium chloride intravenously to bring plasma potassium close to 4 mmol/L to prevent cardiac arrhythmias 4
• Phosphate replacement (20-30 mEq/L potassium phosphate) may be considered in patients with cardiac dysfunction, anemia, respiratory depression, or serum phosphate <1.0 mg/dL 2

Bicarbonate Therapy

• Several studies have shown that bicarbonate administration in patients with DKA made no difference in resolution of acidosis or time to discharge, and its use is generally not recommended 1
• For adult patients, bicarbonate therapy should be individualized and considered only in those with moderately severe acidemia (pH <7.20 and plasma bicarbonate <12 mmol/L) who are at risk for worsening acidemia, particularly if hemodynamically unstable 4
• Bicarbonate should not be administered to children with DKA, except in cases of very severe acidemia with hemodynamic instability refractory to saline administration 4

Monitoring During Treatment

• During therapy, blood should be drawn every 2-4 hours to determine:
  • Serum electrolytes
  • Glucose
  • Blood urea nitrogen
  • Creatinine
  • Osmolality 2
• Monitor for complications, particularly electrolyte imbalances that can trigger cardiac arrhythmias 3
• Watch for signs of cerebral edema, especially in younger patients, including lethargy, behavioral changes, seizures, incontinence, pupillary changes, bradycardia, and respiratory arrest 2

Discharge Planning

• A structured discharge plan should be tailored to the individual patient to reduce length of hospital stay and readmission rates 1
• Information on medication changes, pending tests, and follow-up needs must be accurately and promptly communicated to outpatient healthcare professionals 1
• Schedule follow-up appointments prior to discharge to increase attendance likelihood 1
• Review the following areas of knowledge before discharge:
  • Identification of healthcare professionals who will provide diabetes care after discharge
  • Understanding of diabetes diagnosis, glucose monitoring, home glucose goals, and when to call a healthcare professional
  • Recognition, treatment, and prevention of hyperglycemia and hypoglycemia
  • Information on making healthy food choices
  • Medication administration instructions, including insulin
  • Sick-day management
  • Proper use and disposal of diabetes supplies 1

Special Considerations

• For patients on sodium-glucose cotransporter-2 (SGLT2) inhibitors, be aware of increased risk of DKA and euglycemic DKA 5
• In patients with comorbidities like renal disease, congestive heart failure, acute coronary syndrome, or older age, treatment approaches may need modification 6
• Cerebral edema risk, especially in children, may be minimized by avoiding insulin bolus, excessive saline resuscitation, and decreases in effective plasma osmolality early in treatment 4