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 Management

• Perform thorough clinical and 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
• Insulin therapy must be initiated immediately for children and adolescents with T2DM who are ketotic or in diabetic ketoacidosis 1
• Identify and treat any underlying precipitating cause such as sepsis, myocardial infarction, or stroke 2, 3

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 and 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
• There is no significant difference in outcomes for intravenous human regular insulin versus subcutaneous rapid-acting analogs when combined with aggressive fluid management for treating mild or moderate DKA 1
• Monitor blood glucose every 2-4 hours while the patient takes nothing by mouth and adjust insulin dosing accordingly 1, 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 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 hyperglycaemic 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
• Successful transition from intravenous to subcutaneous insulin requires administration of basal insulin 2–4 h prior to the intravenous insulin being stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia 1

Special Considerations

• When sepsis is identified as the precipitating factor for DKA, treatment must address both conditions simultaneously 3
• Patients with uncomplicated DKA may sometimes be treated with subcutaneous insulin in the emergency department or step-down units, an approach that may be safer and more cost-effective than treatment with intravenous insulin 1
• For patients with ischaemic events (myocardial infarction or ischaemic stroke), rapid control of glucose values might be warranted due to the known potential harms associated with hyperglycemia 1

Transitioning from IV to Subcutaneous Insulin

• Factors to consider when transitioning patients from continuous insulin infusion to subcutaneous insulin include stable glucose measurements for at least 4–6 h consecutively, normal anion gap and resolution of acidosis in DKA, hemodynamic stability (not on vasopressors), stable nutrition plan, and stable intravenous infusion rates 1
• To safely transition to subcutaneous insulin, an estimate of the combined basal and nutritional subcutaneous insulin requirements can be derived from the average amount of insulin infused during the 12 h before transition 1
• Recent studies have reported that the administration of a low dose of basal insulin analog in addition to intravenous insulin infusion may prevent rebound hyperglycemia without increased risk of hypoglycemia 1

Common Pitfalls and Prevention

• 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, 4
• Failure to monitor and replace electrolytes can lead to complications, particularly cardiac arrhythmias 2, 4
• Not identifying or treating the underlying cause of DKA can lead to treatment failure 2, 3
• DKA patients may be normothermic or even hypothermic despite having infection, primarily due to peripheral vasodilation 3
• Abdominal pain in DKA patients may be either a result of the metabolic derangement or a sign of intra-abdominal infection requiring further evaluation 3

Discharge Planning and Prevention

• Provide structured discharge communication including information on medication changes, pending tests, and follow-up needs 1
• Educate patients on diabetes management, self-monitoring of blood glucose, home blood glucose goals, and when to call their provider 1
• Provide education on recognition, treatment, and prevention of hyperglycemia and hypoglycemia 1
• Ensure patients have appropriate medications, supplies, and prescriptions at discharge to avoid dangerous gaps in care 1