From the Guidelines
Management of diabetic ketoacidosis (DKA) in the ICU requires prompt and systematic intervention, with continuous intravenous insulin infusion being the most effective method for achieving specific glycemic goals and avoiding hypoglycemia, as recommended by the most recent guidelines 1. The approach to managing DKA in the ICU involves several key steps:
- Intravenous fluid resuscitation using 0.9% normal saline at 15-20 mL/kg/hr for the first hour, then adjusting to 250-500 mL/hr based on hemodynamic status and fluid deficit.
- Starting insulin therapy with an IV insulin infusion at 0.1 units/kg/hr after initial fluid resuscitation, avoiding insulin boluses, as supported by recent studies 1.
- Monitoring blood glucose hourly, aiming for a decrease of 50-75 mg/dL per hour, and adding dextrose to IV fluids (D5W or D10W) while continuing insulin to clear ketosis when glucose reaches 200-250 mg/dL.
- Addressing electrolyte imbalances by replacing potassium when levels are below 5.2 mEq/L, aiming to maintain levels above 4 mEq/L, and considering bicarbonate therapy only for severe acidosis (pH < 6.9) 1.
- Monitoring electrolytes, glucose, and arterial blood gases every 2-4 hours initially, and identifying and treating the underlying trigger of DKA, such as infection, medication non-adherence, or acute illness.
- Transitioning to subcutaneous insulin when the patient is stable, has resumed eating, and ketoacidosis has resolved (pH > 7.3, bicarbonate > 18 mEq/L, anion gap normalized), with recent studies suggesting the administration of basal insulin 2-4 hours prior to stopping intravenous insulin to prevent recurrence of ketoacidosis and rebound hyperglycemia 1. This approach is supported by the most recent guidelines and studies, which emphasize the importance of individualized treatment and careful monitoring to prevent complications and improve outcomes in patients with DKA 1.
From the Research
Management of Diabetic Ketoacidosis (DKA) in the Intensive Care Unit (ICU)
The management of DKA in the ICU involves several key components, including:
- Fluid resuscitation: The use of isotonic normal saline remains the standard for initial fluid resuscitation, although balanced solutions such as lactated Ringer's have been shown to have faster DKA resolution 2, 3, 4.
- Insulin therapy: Current guidelines recommend using continuous IV insulin for DKA management after fluid status has been restored and potassium levels have been achieved 2. The use of basal insulin analogues, such as insulin glargine, in combination with regular insulin infusion has been shown to accelerate ketoacidosis resolution and prevent rebound hyperglycemia 5.
- Electrolyte replacement: DKA frequently involves multiple electrolyte abnormalities, such as hypokalemia, hypophosphatemia, and hypomagnesemia, and regular monitoring is essential for DKA management 2.
- Prevention of cerebral edema: Rapid overcorrection of hyperglycemia with fluids and insulin can lead to cerebral edema, seizures, and death, and clinicians should be aware of risk factors and preventive strategies for cerebral edema 2, 6.
- Nutrition: Early initiation of oral nutrition has been shown to reduce intensive care unit and overall hospital length of stay 2.
- Airway management: For impending respiratory failure, intubation and mechanical ventilation, with monitoring and management of acid-base and fluid status, are recommended, rather than bilevel positive airway pressure due to aspiration risks 2.
Fluid Management
The choice of fluid for resuscitation in DKA is important, with recent studies suggesting that large volumes of normal saline may lead to undesirable outcomes such as hyperchloremic metabolic acidosis 3, 4. The use of balanced crystalloids, such as lactated Ringer's, may reduce the risk of complications related to hyperchloremia and improve clinical outcomes 3, 4.
Insulin Therapy
The use of continuous IV insulin is recommended for DKA management, with the addition of basal insulin analogues, such as insulin glargine, to prevent rebound hyperglycemia and accelerate ketoacidosis resolution 2, 5. The co-administration of basal insulin with regular insulin infusion has been shown to be well tolerated and associated with faster resolution of acidosis without any adverse effects 5.