What are the immediate management steps for diabetic ketoacidosis (DKA)?

Immediate Management of Diabetic Ketoacidosis (DKA)

The immediate management of diabetic ketoacidosis requires aggressive fluid resuscitation with balanced electrolyte solutions at 15-20 mL/kg/h during the first hour, followed by intravenous insulin therapy with a bolus of 0.15 U/kg and continuous infusion at 0.1 U/kg/h, along with close electrolyte monitoring and replacement. 1

Initial Assessment and Diagnosis

• Initial laboratory evaluation must 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
• Continuous cardiac monitoring is essential in severe DKA to detect arrhythmias early 1
• Direct measurement of β-hydroxybutyrate in blood is the preferred method for monitoring DKA, as the nitroprusside method only measures acetoacetic acid and acetone 1

Fluid Therapy

• Begin with balanced electrolyte solutions rather than 0.9% saline at 15-20 mL/kg/h during the first hour to restore circulatory volume and tissue perfusion 1, 2
• Lactated Ringer's solution may be superior to normal saline as it is associated with faster resolution of high anion gap metabolic acidosis 2
• Continue fluid replacement to correct estimated deficits within the first 24 hours, with an induced change in serum osmolality not exceeding 3 mOsm/kg/h 1
• Monitor fluid input/output, hemodynamic parameters, and clinical examination to assess progress with fluid replacement 1

Insulin Therapy

• 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
• 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
• When glucose falls below 200-250 mg/dL, add dextrose to hydrating solution while continuing insulin infusion to prevent premature termination of insulin therapy 1, 3
• Target blood glucose levels of 100-180 mg/dL 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 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
• Bicarbonate administration is generally not recommended in DKA patients with pH >7.0, as studies have failed to show beneficial effects on clinical outcomes 1, 4
• Consider phosphate replacement only in patients with cardiac dysfunction, anemia, respiratory depression, or serum phosphate <1.0 mg/dL 1

Monitoring and Ongoing Management

• Draw blood every 2-4 hours to determine serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH 1
• Monitor for complications, particularly electrolyte imbalances that can trigger cardiac arrhythmias 1
• Watch for signs of hypoglycemia, which may include sweating, drowsiness, dizziness, anxiety, tremor, hunger, and confusion 3

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, 5
• Common precipitating factors include infection (30-50% of cases, particularly urinary tract infections and pneumonia), intercurrent illnesses, psychological stress, and non-compliance with insulin therapy 5
• SGLT2 inhibitors should be discontinued 3-4 days before surgery to prevent DKA 1

Resolution Parameters and Transition of Care

• DKA resolution requires glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L 1
• Transition from intravenous to subcutaneous insulin requires administration of basal insulin 2-4 hours before the intravenous insulin is stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia 1
• A structured discharge plan should be tailored to the individual to reduce length of hospital stay and readmission rates 1

Common Pitfalls to Avoid

• Premature termination of insulin therapy before complete resolution of ketosis can lead to recurrence of DKA 6
• Inadequate fluid resuscitation can worsen DKA 6
• Failure to identify and treat the underlying cause of DKA 6
• Overly rapid correction of metabolic abnormalities, which can lead to complications 4
• Neglecting to monitor for signs of cerebral edema, especially in children and adolescents 7