What is the initial treatment for mild to moderate Diabetic Ketoacidosis (DKA)?

Initial Treatment for Mild to Moderate Diabetic Ketoacidosis (DKA)

For mild to moderate diabetic ketoacidosis, begin with isotonic saline at 15-20 mL/kg/hour for the first hour followed by continuous intravenous regular insulin at 0.1 units/kg/hour after confirming adequate potassium levels. 1, 2

Initial Assessment and Diagnosis

• Laboratory evaluation should 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 2
• Direct measurement of β-hydroxybutyrate in blood is preferred over nitroprusside method for monitoring DKA 2
• Obtain bacterial cultures and chest X-ray if infection is suspected as a precipitating cause 2, 3

Fluid Therapy

• Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour for the first hour to restore circulatory volume and tissue perfusion 1, 2
• For mild DKA, fluid replacement at 1.5 times the 24-hour maintenance requirements (approximately 5 mL/kg/hour) is sufficient for smooth rehydration 2
• Continue fluid replacement to correct estimated deficits within the first 24 hours, with induced change in serum osmolality not exceeding 3 mOsm/kg/hour 4, 2
• Successful progress with fluid replacement is judged by hemodynamic monitoring, measurement of fluid input/output, and clinical examination 4

Insulin Therapy

• For moderate DKA: Administer an intravenous bolus of regular insulin at 0.15 U/kg body weight, followed by continuous infusion at 0.1 U/kg/hour 4, 2
• For mild DKA: Subcutaneous regular insulin may be given every 4 hours (5-unit increments for every 50 mg/dL increase in blood glucose above 150 mg/dL) 2
• If plasma glucose does not fall by 50 mg/dL in the first hour, double the insulin infusion rate every hour until a steady glucose decline between 50-75 mg/hour is achieved 4, 2
• When plasma glucose reaches 250 mg/dL, decrease insulin infusion to 0.05-0.1 U/kg/hour and add 5-10% dextrose to intravenous fluids 4
• Continue insulin therapy until DKA resolves (glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L) 1, 2

Electrolyte Management

• Monitor potassium levels closely as total body potassium is often depleted despite normal or elevated initial serum levels due to acidosis 2
• Begin potassium replacement after serum levels fall below 5.5 mEq/L, assuming adequate urine output 2
• Add 20-40 mEq/L potassium (2/3 KCl and 1/3 KPO₄) to infusion fluids to maintain serum potassium between 4-5 mEq/L 4, 2
• Delay insulin therapy if initial potassium is <3.3 mEq/L until potassium is restored to avoid arrhythmias, cardiac arrest, and respiratory muscle weakness 2
• Bicarbonate therapy is generally not recommended for patients with pH >7.0 2
• Consider phosphate replacement only in patients with cardiac dysfunction, anemia, respiratory depression, or serum phosphate <1.0 mg/dL 2

Monitoring During Treatment

• Check blood glucose every 2-4 hours while the patient is NPO 2, 3
• Draw blood every 2-4 hours to determine serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH 2
• Monitor fluid input/output, hemodynamic parameters, and clinical examination to assess progress with fluid replacement 2

Transition to Subcutaneous Insulin

• When DKA resolves and the patient can eat, transition to a multiple-dose insulin regimen using a combination of short/rapid-acting and intermediate/long-acting insulin 1, 2
• Administer basal insulin 2-4 hours before stopping the IV insulin infusion to prevent recurrence of ketoacidosis 2
• For newly diagnosed patients, initiate a multidose regimen at approximately 0.5-1.0 units/kg/day 2

Prevention of Complications

• Thromboprophylaxis with enoxaparin should be considered as part of standard hospital protocols due to the hypercoagulable state associated with DKA 1
• Monitor for cerebral edema, especially in pediatric patients, by following recommendations for gradual correction of glucose and osmolality 2
• Carefully monitor for electrolyte imbalances that can trigger cardiac arrhythmias 2