How to manage Diabetic Ketoacidosis (DKA)?

Management of Diabetic Ketoacidosis (DKA)

The management of DKA requires aggressive fluid resuscitation with isotonic saline at 15-20 ml/kg/hour initially, followed by continuous intravenous insulin at 0.1 units/kg/hour without an initial bolus, while monitoring electrolytes closely and addressing precipitating factors. 1, 2, 3

Initial Assessment and Diagnosis

• Perform laboratory evaluation including plasma glucose, blood urea nitrogen/creatinine, serum ketones, electrolytes with calculated anion gap, osmolality, urinalysis, urine ketones, arterial blood gases, complete blood count, and electrocardiogram 1, 3
• Obtain bacterial cultures (urine, blood, throat) if infection is suspected and administer appropriate antibiotics 1
• Diagnostic criteria for DKA: plasma glucose >250 mg/dl, arterial pH <7.30, serum bicarbonate <18 mEq/l, and positive serum and urine ketones 1
• Direct measurement of β-hydroxybutyrate in blood is the preferred method for monitoring DKA as nitroprusside method only measures acetoacetic acid and acetone 2, 4

Fluid Therapy

• Begin with isotonic saline (0.9% NaCl) at a rate of 15-20 ml/kg body weight/hour during the first hour to restore intravascular volume and renal perfusion 1, 3
• Subsequent fluid choice depends on hydration status, serum electrolyte levels, and urine output 1
• Total fluid replacement should be approximately 1.5 times the 24-hour maintenance requirements 3
• For patients without severe volume depletion, a more moderate infusion rate of 500 ml/hour may be equally effective as 1000 ml/hour 5

Insulin Therapy

• Start continuous intravenous regular insulin infusion at 0.1 units/kg/hour without an initial bolus for moderate to severe DKA 2, 3
• If plasma glucose does not fall by 50 mg/dl in the first hour, double the insulin infusion rate hourly until a steady glucose decline between 50-75 mg/hour is achieved 2
• When serum glucose reaches 250 mg/dl, decrease insulin infusion to 0.05-0.1 units/kg/hour and add dextrose to IV fluids to prevent hypoglycemia while continuing insulin to clear ketosis 2, 4
• For mild DKA, subcutaneous rapid-acting insulin analogs can be effective when combined with aggressive fluid management 4
• Continue insulin therapy until resolution of ketoacidosis (pH >7.3, serum bicarbonate ≥18 mEq/l, and anion gap ≤12 mEq/l), regardless of glucose levels 2, 4

Electrolyte Management

• Monitor potassium levels closely as insulin therapy and correction of acidosis can cause hypokalemia 1, 2
• Include 20-30 mEq/L potassium in IV fluids once renal function is assured and serum potassium is <5.3 mEq/L 3
• If initial potassium is low (<3.3 mEq/L), temporarily delay insulin administration and first administer potassium chloride to bring levels close to 4 mmol/L 6
• Maintain serum potassium between 4-5 mmol/L throughout treatment 4
• Monitor phosphate and magnesium levels and replace as needed 7

Monitoring During Treatment

• Check blood glucose every 1-2 hours 2
• Draw blood every 2-4 hours to determine serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH 2, 4
• Follow venous pH (typically 0.03 units lower than arterial pH) and anion gap to monitor resolution of acidosis 4

Bicarbonate Administration

• Bicarbonate administration is generally not recommended for DKA patients with pH >6.9 2, 4
• Consider bicarbonate in adult patients with moderately severe acidemia (pH <7.20 and plasma bicarbonate <12 mmol/L) who are at risk for worsening acidemia, particularly if hemodynamically unstable 6
• Bicarbonate should not be administered to children with DKA, except if acidemia is very severe and hemodynamic instability is refractory to saline administration 6

Transition to Subcutaneous Insulin

• When DKA resolves (glucose <200 mg/dl, serum bicarbonate ≥18 mEq/l, venous pH >7.3, and anion gap ≤12 mEq/L), transition to subcutaneous insulin 2, 4
• Administer basal insulin 2-4 hours before stopping the IV insulin infusion to prevent recurrence of ketoacidosis 4, 3
• Start a multiple-dose schedule using a combination of short/rapid-acting and intermediate/long-acting insulin when the patient is able to eat 4, 3

Common Pitfalls to Avoid

• Premature termination of insulin therapy before complete resolution of ketosis can lead to recurrence of DKA 2, 4
• Inadequate monitoring of potassium levels during insulin therapy can cause dangerous hypokalemia 2, 8
• Interruption of insulin infusion when glucose levels fall without adding dextrose is a common cause of persistent or worsening ketoacidosis 4
• Rapid overcorrection of hyperglycemia can lead to cerebral edema, particularly in children 7, 6
• Relying on nitroprusside method to measure ketones is misleading as it only measures acetoacetic acid and acetone, not β-hydroxybutyrate 2

Special Considerations

• In patients with heart failure or renal failure, fluid administration should be more cautious to avoid fluid overload 9
• For pregnant patients, fetal monitoring should be considered during DKA treatment 10
• In patients taking SGLT2 inhibitors, DKA can occur with only mildly elevated glucose levels (euglycemic DKA) 10, 7
• Cerebral edema risk may be minimized by avoiding insulin bolus, excessive saline resuscitation, and rapid decrease in effective plasma osmolality early in treatment 6