What is the management of Diabetic Ketoacidosis (DKA)?

Management of Diabetic Ketoacidosis (DKA)

The management of diabetic ketoacidosis requires aggressive fluid resuscitation, insulin therapy, electrolyte replacement, and identification and treatment of precipitating causes, with continuous monitoring until resolution of acidosis and ketosis. 1, 2

Diagnosis and Initial Assessment

• Initial laboratory evaluation should include plasma glucose, blood urea nitrogen, creatinine, serum ketones, electrolytes with calculated anion gap, osmolality, urinalysis, arterial blood gases, complete blood count with differential, and electrocardiogram 1
• Direct measurement of β-hydroxybutyrate in blood is the preferred method for monitoring DKA, as it more accurately reflects ketone levels than urine ketones 1
• DKA is diagnosed by the triad of hyperglycemia (blood glucose >250 mg/dL), metabolic acidosis (pH <7.3, serum bicarbonate <18 mEq/L, anion gap >10 mEq/L), and elevated serum or urine ketones 2, 3
• Euglycemic DKA (normal or minimally elevated blood glucose) should be considered in patients taking SGLT2 inhibitors 3

Fluid Therapy

• Begin with balanced electrolyte solutions at a rate of 15-20 mL/kg/h during the first hour to restore circulatory volume and tissue perfusion 1, 2
• Continue fluid replacement to correct estimated deficits within the first 24 hours, with careful monitoring to avoid rapid changes in serum osmolality 1
• When serum glucose reaches 250 mg/dL, change fluid to 5% dextrose with 0.45-0.75% NaCl while continuing insulin therapy to help resolve ketosis 2
• Monitor fluid input/output, hemodynamic parameters, and clinical examination to assess progress with fluid replacement 1, 2

Insulin Therapy

• For critically ill and mentally obtunded patients, administer an intravenous bolus of regular insulin at 0.15 U/kg body weight, followed by a continuous infusion at 0.1 U/kg/h 1, 4
• If plasma glucose does not fall by 50 mg/dL from the initial value in the first hour, double the insulin infusion every hour until a steady glucose decline between 50-75 mg/h is achieved 1
• 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 2
• For mild or moderate uncomplicated DKA, subcutaneous rapid-acting insulin analogs combined with aggressive fluid management can be as effective as intravenous insulin 4, 2

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
• In patients with DKA and a relatively low plasma potassium level, temporarily delay insulin administration and first administer potassium chloride intravenously to bring the plasma potassium level close to 4 mmol/L to prevent cardiac arrhythmias 5
• Bicarbonate therapy is generally not recommended in DKA patients with pH >7.0, as studies have failed to show beneficial effects on clinical outcomes 1, 2
• Consider phosphate replacement only in patients with cardiac dysfunction, anemia, respiratory depression, or serum phosphate <1.0 mg/dL 1

Monitoring During Treatment

• Draw blood every 2-4 hours to determine serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH 1, 2
• Monitor for complications, particularly electrolyte imbalances that can trigger cardiac arrhythmias 1
• Target blood glucose levels of 100-180 mg/dL 1
• Follow venous pH and anion gap to monitor resolution of acidosis 2

Resolution Parameters and Transition to Subcutaneous Insulin

• DKA resolution requires glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L 1, 2
• When transitioning to subcutaneous insulin, administer basal insulin 2-4 hours before stopping the intravenous insulin to prevent recurrence of ketoacidosis and rebound hyperglycemia 4, 1, 2
• Recent studies suggest that administration of a low dose of basal insulin analog in addition to intravenous insulin infusion may prevent rebound hyperglycemia without increased risk of hypoglycemia 2

Identification and Treatment of Precipitating Causes

• Obtain bacterial cultures of urine, blood, and other sites as needed and administer appropriate antibiotics if infection is suspected 1
• Common precipitating factors include infection, myocardial infarction, stroke, and medication non-adherence 2, 6
• SGLT2 inhibitors should be discontinued 3-4 days before surgery to prevent DKA 1

Special Populations

• In pregnant patients, DKA management requires close monitoring and coordination with obstetric care 6
• Patients with chronic kidney disease require careful fluid and electrolyte management 6
• In children, avoid rapid changes in serum osmolality to reduce the risk of cerebral edema, which is the most common cause of mortality and morbidity in pediatric DKA 5
• Sodium bicarbonate should not be administered to children with DKA, except if acidemia is very severe and hemodynamic instability is refractory to saline administration 5

Discharge Planning and Prevention

• Develop a structured discharge plan tailored to the individual patient to reduce length of hospital stay and readmission rates 4, 2
• Schedule follow-up appointments prior to discharge to increase the likelihood of attendance 2
• Transmit discharge summaries to the primary care provider as soon as possible after discharge 4, 2
• Include education on the recognition, prevention, and management of DKA for all individuals affected by or at high risk for these events to prevent recurrence and readmission 2