What are the guidelines for managing diabetic ketoacidosis (DKA)?

Management of Diabetic Ketoacidosis (DKA)

The management of diabetic ketoacidosis requires immediate fluid resuscitation with balanced electrolyte solutions, followed by intravenous insulin therapy, careful electrolyte monitoring and replacement, and identification of precipitating factors. 1

Diagnosis and Initial Assessment

• 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
• Direct measurement of β-hydroxybutyrate in blood is preferred for monitoring DKA, as the nitroprusside method only measures acetoacetic acid and acetone 1
• Continuous cardiac monitoring is essential in severe DKA to detect arrhythmias early 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
• Recent evidence suggests balanced electrolyte solutions result in faster DKA resolution compared to 0.9% saline 2
• Continue fluid replacement to correct estimated deficits within the first 24 hours, ensuring induced change in serum osmolality does not exceed 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 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
• Target blood glucose levels of 100-180 mg/dL during treatment 1
• Add dextrose to IV fluids when blood glucose falls below 200-250 mg/dL while continuing insulin infusion to clear ketones 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
• Monitor for complications, particularly electrolyte imbalances that can trigger cardiac arrhythmias 1
• In children and adolescents, carefully monitor for signs of cerebral edema (lethargy, behavioral changes, seizures, incontinence, pupillary changes, bradycardia, respiratory arrest) 3

Transition from IV to Subcutaneous Insulin

• 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
• DKA resolution requires glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L 1

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
• Discontinue SGLT2 inhibitors 3-4 days before surgery to prevent DKA 1
• Common precipitating factors include infection, inadequate insulin therapy, new-onset diabetes, and physiologic stress 4

Discharge Planning and Prevention

• Develop a structured discharge plan 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 attendance likelihood 5

Special Considerations for Pediatric Patients

• Cerebral edema is responsible for most DKA-related deaths in children 3
• Risk factors for cerebral edema include severity of acidosis, greater hypocapnia, higher blood urea nitrogen at presentation, and treatment with bicarbonate 3
• After initial volume expansion, fluid resuscitation in children should be calculated to rehydrate evenly over at least 48 hours 3