What are the steps for treating diabetic ketoacidosis (DKA)?

Management of Diabetic Ketoacidosis (DKA): A Stepwise Approach

The treatment of diabetic ketoacidosis requires immediate fluid resuscitation with isotonic saline, followed by insulin therapy, electrolyte replacement, and identification of precipitating causes, with close monitoring throughout the process to prevent complications. 1

Step 1: Initial Assessment and Diagnosis

• Confirm DKA diagnosis using laboratory criteria: blood glucose >250 mg/dl, arterial pH <7.3, bicarbonate <15 mEq/l, and moderate ketonuria or ketonemia 2
• Obtain comprehensive laboratory evaluation including plasma glucose, blood urea nitrogen/creatinine, serum ketones, electrolytes with calculated anion gap, osmolality, urinalysis, arterial blood gases, complete blood count, and electrocardiogram 1
• Collect bacterial cultures (urine, blood, throat) if infection is suspected and obtain chest X-ray if clinically indicated 3
• Calculate corrected serum sodium (for each 100 mg/dl glucose >100 mg/dl, add 1.6 mEq to sodium value) 2

Step 2: Fluid Therapy

• Begin with isotonic saline (0.9% NaCl) at 15-20 ml/kg/hour (approximately 1-1.5 L in average adult) during the first hour to restore circulatory volume and tissue perfusion 1, 2
• After initial resuscitation, adjust fluid choice based on hydration status, serum electrolytes, and urine output:
  • If corrected serum sodium is normal or elevated: use 0.45% NaCl at 4-14 ml/kg/hour 2
  • If corrected serum sodium is low: continue with 0.9% NaCl at similar rate 2
• Total fluid replacement should correct estimated deficits (typically 6L or 100 ml/kg) within 24 hours 2, 4
• When blood glucose reaches 250-300 mg/dl, add dextrose to hydrating solution while continuing insulin infusion at reduced rate 4

Step 3: Insulin Therapy

• Once hypokalemia (K+ <3.3 mEq/L) is excluded, administer intravenous bolus of regular insulin at 0.15 U/kg body weight, followed by continuous infusion at 0.1 U/kg/hour 1, 3
• If plasma glucose does not fall by 50 mg/dl from initial value in first hour, double insulin infusion every hour until steady glucose decline between 50-75 mg/hour is achieved 1
• Continue insulin infusion until DKA resolves (glucose <200 mg/dl, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L) 1
• For mild DKA, subcutaneous regular insulin may be given every 4 hours instead of IV infusion 1

Step 4: Electrolyte Management

• Monitor potassium levels closely as total body potassium is depleted despite potentially normal or elevated initial serum levels due to acidosis 1
• Once renal function is assured and serum potassium is known, add 20-30 mEq/L potassium (2/3 KCl and 1/3 KPO4) to each liter of infusion fluid when serum levels fall below 5.5 mEq/L 1, 2
• If significant hypokalemia (<3.3 mEq/L) is present initially, delay insulin treatment until potassium concentration is restored to avoid arrhythmias, cardiac arrest, and respiratory muscle weakness 1
• Consider phosphate replacement only in patients with cardiac dysfunction, anemia, respiratory depression, or serum phosphate <1.0 mg/dL 1

Step 5: Bicarbonate Therapy

• Bicarbonate therapy is generally not recommended for patients with pH >7.0 1, 5
• For adult patients with severe acidemia:
  • pH <6.9: administer 100 mmol sodium bicarbonate in 400 mL sterile water at 200 mL/hour 1, 6
  • pH 6.9-7.0: administer 50 mmol sodium bicarbonate in 200 mL sterile water at 200 mL/hour 1
• Bicarbonate should not be administered to children with DKA except in cases of very severe acidemia with hemodynamic instability 7

Step 6: Monitoring During Treatment

• Check blood glucose every 2-4 hours while patient is NPO 1, 3
• Draw blood every 2-4 hours to determine serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH 1
• Monitor fluid input/output, hemodynamic parameters, and clinical examination to assess progress with fluid replacement 1
• Watch for signs of cerebral edema (lethargy, behavioral changes, seizures, incontinence, pupillary changes, bradycardia, respiratory arrest) especially in children 4, 8
• Target blood glucose levels of 100-180 mg/dl 1

Step 7: Transition to Subcutaneous Insulin

• When DKA resolves and patient can eat, transition to multiple-dose insulin regimen using combination of short/rapid-acting and intermediate/long-acting insulin 1, 3
• Administer basal insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia 1, 4
• For newly diagnosed patients, initiate multidose regimen at approximately 0.5-1.0 units/kg/day 1

Step 8: Prevention of Complications

• Cerebral edema risk may be minimized by avoiding insulin bolus, excessive saline resuscitation, and rapid decrease in effective plasma osmolality 7, 8
• Hypoglycemia, hypokalemia, and hyperchloremic metabolic acidosis are potential complications of treatment that require vigilant monitoring 4
• Balanced crystalloid solutions may lead to faster resolution of acidosis compared to normal saline 9, 5

Step 9: Identification and Treatment of Precipitating Causes

• Common precipitating factors include infection, new-onset diabetes, insulin omission, and drugs affecting carbohydrate metabolism (corticosteroids, thiazides, sympathomimetic agents) 2
• Administer appropriate antibiotics if infection is suspected 1, 3
• SGLT2 inhibitors should be discontinued 3-4 days before surgery to prevent DKA 1

Step 10: Discharge Planning and Prevention

• Provide education on recognition, prevention, and management of DKA 1
• Create structured discharge plan tailored to individual patient to reduce length of hospital stay and readmission rates 1, 3