What is the management approach for diabetes ketoacidosis (DKA)?

Management of Diabetic Ketoacidosis (DKA)

The management of diabetic ketoacidosis requires immediate treatment with fluid resuscitation, insulin therapy, electrolyte replacement, and identification of underlying causes to prevent morbidity and mortality. 1, 2

Initial Assessment and Stabilization

• Perform comprehensive laboratory assessment including plasma glucose, blood urea nitrogen, creatinine, serum ketones, electrolytes with calculated anion gap, osmolality, urinalysis, arterial blood gases, and complete blood count 2
• Identify and treat any precipitating factors such as infection (most common), myocardial infarction, or stroke 3, 2
• Patients presenting with ketosis or in diabetic ketoacidosis where distinction between Type 1 and Type 2 diabetes is unclear must receive insulin therapy 1

Fluid Resuscitation

• Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour during the first hour to restore circulatory volume and tissue perfusion 2
• Continue fluid replacement based on hemodynamic status, serum electrolyte levels, and urine output 2
• Management goals include restoration of circulatory volume, tissue perfusion, resolution of hyperglycemia/ketoacidosis, and correction of electrolyte imbalances 1

Insulin Therapy

• Continuous intravenous insulin is the standard of care for critically ill and mentally obtunded patients with DKA 1, 2
• For mild or moderate uncomplicated DKA, subcutaneous rapid-acting insulin analogs may be used when combined with aggressive fluid management 1
• Monitor blood glucose every 2-4 hours while the patient takes nothing by mouth and adjust insulin dosing accordingly 1, 2
• Successful transition from intravenous to subcutaneous insulin requires administration of basal insulin 2–4 hours before stopping intravenous insulin to prevent recurrence of ketoacidosis and rebound hyperglycemia 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 2
• Add 20-40 mEq/L potassium to the infusion when serum levels fall below 5.5 mEq/L 2
• Hypokalaemia is common (about 50%) during treatment of hyperglycemic crises, and severe hypokalaemia (<2.5 mEq/L) is associated with increased inpatient mortality 1
• Bicarbonate administration is generally not recommended, as studies have shown it makes no difference in resolution of acidosis or time to discharge 1

Monitoring for Resolution

• Draw blood every 2-4 hours to determine serum electrolytes, glucose, blood urea nitrogen, creatinine, and osmolality during therapy 2
• Treatment success is indicated by resolution of acidosis (pH >7.3), serum bicarbonate ≥18 mEq/L, anion gap ≤12 mEq/L, and improvement in clinical symptoms 2
• For transition from IV to subcutaneous insulin, ensure stable glucose measurements for at least 4–6 hours consecutively, normal anion gap, resolution of acidosis, hemodynamic stability, and stable nutrition plan 1

Special Considerations

• Patients on SGLT2 inhibitors may develop euglycemic DKA, requiring insulin therapy despite relatively normal blood glucose levels 4
• Patients with chronic kidney disease may require modified fluid and electrolyte management 5
• Pregnant patients with DKA require specialized management and close monitoring 5
• In patients with type 1 or insulin-dependent diabetes, prolonged hyperglycemia can result in DKA, which is a life-threatening emergency 6

Transition from Hospital and Discharge Planning

• Begin discharge planning at admission and update as patient needs change 2
• Provide patients with appropriate education about:
  • Definition, recognition, treatment, and prevention of hyperglycemia and hypoglycemia 1
  • When and how to take blood glucose-lowering medications, including insulin administration 1
  • Information on making healthy food choices 1
• Schedule follow-up appointments prior to discharge to increase attendance likelihood 2

Common Pitfalls to Avoid

• Inadequate fluid resuscitation can delay recovery and worsen outcomes 2
• Premature discontinuation of insulin therapy before complete resolution of ketosis can lead to recurrence of DKA 2, 7
• Failure to monitor and replace electrolytes can lead to complications, particularly cardiac arrhythmias 2
• Not identifying or treating the underlying cause of DKA can lead to treatment failure 3, 2
• Patients with DKA may be normothermic or even hypothermic despite having infection, primarily due to peripheral vasodilation 3

Prevention Strategies

• Patient education focusing on adherence to insulin and self-care guidelines during illness 8
• Improved access to medical providers and support services 8
• Identifying diabetes before DKA develops through screening programs 4
• Ensuring uninterrupted access to diabetes therapies 4, 8