Diabetic Ketoacidosis (DKA) Treatment and Diagnosis
The recommended treatment for Diabetic Ketoacidosis (DKA) consists of isotonic saline fluid resuscitation at 15-20 ml/kg/hour initially, continuous intravenous regular insulin at 0.1 units/kg/hour after a 0.1 units/kg bolus, and careful electrolyte management with close monitoring until resolution. 1
Diagnosis of DKA
- DKA diagnosis requires laboratory evaluation including plasma glucose, blood urea nitrogen/creatinine, serum ketones, electrolytes, osmolality, urinalysis, urine ketones, arterial blood gases, complete blood count, and electrocardiogram 1
- Obtain bacterial cultures (urine, blood, throat) if infection is suspected, and administer appropriate antibiotics 1
- Chest X-ray should be obtained if clinically indicated 1
Treatment Algorithm
1. Fluid Resuscitation
- Begin with isotonic saline at 15-20 ml/kg body weight/hour for the first hour 1
- Total fluid replacement should be approximately 1.5 times the 24-hour maintenance requirements 1
- After initial volume expansion, rehydration should be calculated to occur evenly over at least 48 hours in children to reduce risk of cerebral edema 2
2. Insulin Therapy
- Administer continuous intravenous regular insulin infusion as the preferred treatment method for moderate to severe DKA 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
- Continue insulin therapy until DKA resolves (normalization of pH, bicarbonate, and closure of anion gap) 1, 3
- FDA data shows intravenous Humulin R U-100 is effective in normalizing blood glucose, with most patients achieving target glucose levels (100-160 mg/dL) within approximately 161 minutes 4
3. Electrolyte Management
- Include 20-30 mEq/L potassium in the infusion once renal function is assured and serum potassium is known 1
- Monitor serum potassium closely as insulin therapy lowers serum potassium levels 1
- Phosphate replacement (20-30 mEq/L potassium phosphate) may be considered in patients with cardiac dysfunction, anemia, respiratory depression, or serum phosphate <1.0 mg/dL 5
4. Monitoring
- 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
- Monitor for signs of cerebral edema, particularly in children and adolescents (lethargy, behavioral changes, seizures, incontinence, pupillary changes, bradycardia, respiratory arrest) 5, 2
5. Transition to Subcutaneous Insulin
- When DKA resolves and the 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 to prevent rebound hyperglycemia 1, 5
Special Considerations
- Bicarbonate Administration: Generally not recommended in most patients 6, 7. May be considered only if serum pH falls below 6.9 or when serum pH is less than 7.2 and/or serum bicarbonate levels are below 10 mEq/L 3
- Cerebral Edema Risk: More common in children and adolescents. Risk factors include severity of acidosis, greater hypocapnia, higher blood urea nitrogen at presentation, and treatment with bicarbonate 2
- Early Nutrition: Early initiation of oral nutrition has been shown to reduce intensive care unit and overall hospital length of stay 3
- Airway Management: For impending respiratory failure, intubation and mechanical ventilation with careful monitoring of acid-base and fluid status is recommended rather than BiPAP due to aspiration risks 3
Potential Complications to Monitor
- Hypoglycemia and hypokalemia due to overzealous insulin treatment 5
- Hyperchloremic metabolic acidosis from excessive saline administration 5
- Cerebral edema, especially in pediatric patients 2, 3