What is the management of diabetic ketoacidosis?

Management of Diabetic Ketoacidosis (DKA)

The management of diabetic ketoacidosis requires immediate intravenous insulin therapy to rapidly correct hyperglycemia and metabolic derangements, along with aggressive fluid resuscitation and electrolyte replacement, followed by identification and treatment of precipitating causes. 1

Initial Assessment and Diagnosis

• 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 preferred for monitoring DKA, as nitroprusside methods only measure acetoacetic acid and acetone 1
• DKA is characterized 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
• Be alert for euglycemic DKA, particularly in patients taking SGLT2 inhibitors, where blood glucose may not be significantly elevated 2

Fluid Therapy

• Begin with isotonic saline at 15-20 mL/kg/h during the first hour to restore circulatory volume and tissue perfusion 1
• Continue fluid replacement to correct estimated deficits within the first 24 hours, with careful monitoring to prevent rapid changes in serum osmolality 1
• Monitor fluid input/output, hemodynamic parameters, and clinical examination to assess progress with fluid replacement 1
• Switch to 5% glucose in 0.45% saline when blood glucose reaches 250-300 mg/dL to prevent hypoglycemia while continuing insulin infusion 3

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
• Continue insulin infusion until acidosis resolves (pH >7.3, bicarbonate ≥18 mEq/L, and anion gap ≤12 mEq/L) 1
• For transition from IV to subcutaneous insulin, administer basal insulin 2-4 hours before stopping the IV insulin to prevent recurrence of ketoacidosis 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 therapy is generally not recommended in DKA patients with pH >7.0, as studies have failed to show beneficial effects on clinical outcomes 1
• 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
• Target blood glucose levels of 100-180 mg/dL during treatment 1
• Monitor for complications, particularly electrolyte imbalances that can trigger cardiac arrhythmias 1
• DKA resolution requires glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L 1

Special Populations Considerations

Children and Adolescents

• In youth with ketoacidosis, treatment with subcutaneous or intravenous insulin should be initiated to rapidly correct hyperglycemia and metabolic derangement 4
• Once acidosis is resolved, metformin should be initiated while subcutaneous insulin therapy is continued 4
• Insulin therapy must be initiated for children and adolescents with T2DM who are ketotic or in diabetic ketoacidosis and in whom the distinction between T1DM and T2DM is unclear 4

Patients with Comorbidities

• Management requires special consideration in patients with chronic kidney disease, pregnancy, or those taking SGLT2 inhibitors 5
• SGLT2 inhibitors should be discontinued 3-4 days before surgery to prevent DKA 1
• Patients with heart failure require careful fluid management to prevent volume overload 6

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, non-compliance with insulin therapy, new-onset diabetes, myocardial infarction, stroke, and medications like SGLT2 inhibitors 2
• Address the underlying cause to prevent recurrence 1

Discharge Planning and Prevention

• A structured discharge plan should be tailored to the individual to reduce length of hospital stay and readmission rates 1
• Include education on the recognition, prevention, and management of DKA for all individuals affected by or at high risk for these events 1
• Schedule follow-up appointments prior to discharge to increase the likelihood that patients will attend 7

Common Pitfalls to Avoid

• Failure to recognize euglycemic DKA, especially in patients taking SGLT2 inhibitors 2
• Overly rapid correction of fluid deficits, which can lead to cerebral edema, particularly in children 8
• Premature discontinuation of insulin infusion before acidosis resolves 1
• Inadequate potassium replacement, which can lead to life-threatening arrhythmias 1
• Failure to identify and treat the precipitating cause, leading to recurrence 1
• Transitioning from IV to subcutaneous insulin without overlap, resulting in recurrent ketoacidosis 1