What is the recommended treatment for diabetic ketoacidosis (DKA) in South Africa?

Treatment of Diabetic Ketoacidosis in South Africa

The recommended treatment for diabetic ketoacidosis (DKA) in South Africa should follow a structured approach focusing on fluid resuscitation, insulin therapy, electrolyte management, and identification of precipitating causes.

Initial Assessment and Stabilization

• Perform laboratory evaluation including plasma glucose, blood urea nitrogen/creatinine, serum ketones, electrolytes (with calculated anion gap), osmolality, urinalysis, urine ketones, arterial blood gases, complete blood count, and electrocardiogram 1
• Obtain bacterial cultures of urine, blood, and throat if infection is suspected and administer appropriate antibiotics 1
• Chest X-ray should be obtained if clinically indicated 1

Fluid Resuscitation

• Begin with isotonic saline (0.9% NaCl) at a rate of 15-20 ml/kg body weight/hour (approximately 1-1.5 liters in the average adult) during the first hour 1
• Subsequent fluid choice depends on hydration status, serum electrolyte levels, and urinary output:
  • Use 0.45% NaCl at 4-14 ml/kg/hour if corrected serum sodium is normal or elevated 1
  • Use 0.9% NaCl at similar rate if corrected serum sodium is low 1
• Total fluid replacement should be approximately 1.5 times the 24-hour maintenance requirements 1

Insulin Therapy

• For moderate to severe DKA, continuous intravenous regular insulin infusion is the preferred treatment method 1
• Start with an IV bolus of regular insulin at 0.1 units/kg followed by continuous infusion at 0.1 units/kg/hour 1
• For mild DKA, subcutaneous or intramuscular insulin administration can be effective:
  • Give a "priming" dose of regular insulin of 0.4-0.6 units/kg, half as IV bolus and half as subcutaneous/intramuscular injection 1
  • Follow with 0.1 unit/kg of regular insulin subcutaneously or intramuscularly every hour 1
• Alternative approach for mild to moderate DKA: combination of rapid-acting and basal subcutaneous insulin (CRABI) with glargine (0.2 units/kg) and rapid-acting insulin (0.2 units/kg) initially, followed by rapid-acting insulin (0.1-0.2 units/kg) every 3 hours 2

Electrolyte Management

• Once renal function is assured, include 20-30 mEq/L potassium (2/3 KCl and 1/3 KPO4) in the infusion 1
• Monitor serum potassium closely as insulin therapy lowers serum potassium levels 1
• For patients with pH 6.9-7.0, administer 50 mmol sodium bicarbonate diluted in 200 ml sterile water and infused at 200 ml/hour 1
• Bicarbonate therapy is not necessary if pH is >7.0 1
• Consider phosphate replacement in patients with cardiac dysfunction, anemia, respiratory depression, or serum phosphate <1.0 mg/dl 1

Monitoring During Treatment

• Check blood glucose every 2-4 hours 1
• Measure serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH every 2-4 hours 1
• Follow venous pH (usually 0.03 units lower than arterial pH) and anion gap to monitor resolution of acidosis 1
• Do not use nitroprusside method to assess urinary or serum ketone levels as an indicator of response to therapy 1

Criteria for DKA Resolution

• Blood glucose <200 mg/dl 1
• Serum bicarbonate ≥18 mEq/l 1
• Venous pH >7.3 1
• Clinical improvement 3

Transition from IV to Subcutaneous Insulin

• When DKA resolves and patient can eat, start a multiple-dose insulin schedule using a combination of short/rapid-acting and intermediate/long-acting insulin 1
• Administer basal insulin 2-4 hours before stopping the IV insulin infusion 3
• Continue IV insulin infusion for 1-2 hours after starting subcutaneous insulin to ensure adequate plasma insulin levels 1, 3
• Calculate total daily insulin requirement by multiplying hourly insulin drip rate by 24 hours 3
• Basal insulin dose should be 40-50% of the total daily dose 3

Common Pitfalls to Avoid

• Inadequate fluid resuscitation 4
• Premature discontinuation of insulin therapy before complete resolution of ketosis 4
• Failure to monitor and replace electrolytes 4, 3
• Abrupt discontinuation of IV insulin without overlapping with subcutaneous insulin 3
• Inadequate carbohydrate administration alongside insulin in euglycemic DKA 4

Special Considerations

• For euglycemic DKA, ensure adequate carbohydrate administration alongside insulin to prevent perpetuation of ketosis 4
• In patients with cardiac or renal compromise, adjust fluid administration rates accordingly 5
• For patients with type 1 diabetes, ensure resumption of their previous insulin regimen at appropriate doses 3
• Most patients can be managed outside of intensive care units unless they have cardiovascular instability, airway compromise, obtundation, or acute abdominal symptoms 6