What are the initial management steps for Diabetic Ketoacidosis (DKA)?

Initial Management of Diabetic Ketoacidosis (DKA)

The initial management of Diabetic Ketoacidosis (DKA) requires immediate intervention with intravenous fluids, insulin therapy, electrolyte replacement, and identification of precipitating factors to reduce morbidity and mortality. 1

Diagnosis and Initial Assessment

• Confirm DKA diagnosis with plasma glucose >250 mg/dL, pH <7.3, serum bicarbonate <18 mEq/L, and elevated serum ketones 2
• Obtain immediate 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 ECG 1
• Direct measurement of β-hydroxybutyrate in blood is preferred for monitoring DKA, as the nitroprusside method only measures acetoacetic acid and acetone 1
• Identify precipitating factors such as infection, myocardial infarction, stroke, medication non-adherence, or SGLT2 inhibitor use 3

Fluid Therapy

• Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour during the first hour to restore circulatory volume and tissue perfusion 1, 3
• For mild DKA, administer fluids at 1.5 times the 24-hour maintenance requirements (5 mL/kg/h) for smooth rehydration; do not exceed twice the maintenance requirement 4
• Continue fluid replacement based on hemodynamic status, serum electrolyte levels, and urine output 3
• Monitor fluid input/output and clinical examination to assess progress with fluid replacement 1

Insulin Therapy

• For critically ill and mentally obtunded patients with DKA, 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, 3
• If plasma glucose does not fall by 50 mg/dL from the 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
• For mild DKA, subcutaneous rapid-acting insulin analogs may be used when combined with aggressive fluid management 3
• Continue insulin therapy until resolution of ketoacidosis (pH >7.3, serum bicarbonate ≥18 mEq/L, and anion gap ≤12 mEq/L) 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, 3
• Begin potassium replacement after serum levels fall below 5.5 mEq/L, assuming adequate urine output 1
• Add 20-40 mEq/L potassium (2/3 KCl and 1/3 KPO4) to the infusion fluid to maintain serum potassium concentration within 4-5 mEq/L 1
• If significant hypokalemia is present initially (<3.3 mEq/L), delay insulin treatment until potassium concentration is restored to avoid arrhythmias, cardiac arrest, and respiratory muscle weakness 1

Bicarbonate Therapy

• Bicarbonate therapy is generally not recommended in DKA patients with pH >7.0, as studies have failed to show beneficial effects on clinical outcomes 4, 1
• For adult patients with pH <6.9, administer 100 mmol sodium bicarbonate in 400 mL sterile water at 200 mL/h 1
• For patients with pH 6.9-7.0, administer 50 mmol sodium bicarbonate in 200 mL sterile water at 200 mL/h 1

Monitoring During Treatment

• Draw blood every 2-4 hours to determine serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH 1
• Monitor blood glucose at least every 2-4 hours while the patient takes nothing by mouth 3
• Target blood glucose levels of 100-180 mg/dL 1
• Venous pH (typically 0.03 units lower than arterial pH) and anion gap can be followed to monitor resolution of acidosis 1

Transition from IV to Subcutaneous Insulin

• When DKA is resolved (glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L), transition to subcutaneous insulin if the patient can eat 1
• Administer basal insulin 2-4 hours before discontinuing intravenous insulin to prevent recurrence of ketoacidosis and rebound hyperglycemia 1, 3
• For newly diagnosed patients, initiate a multidose regimen of short- and intermediate/long-acting insulin at approximately 0.5-1.0 units/kg/day 1
• Continue intravenous insulin infusion for 1-2 hours after the subcutaneous insulin regimen is begun to ensure adequate plasma insulin levels 4

Common Pitfalls and Complications

• Inadequate fluid resuscitation can delay recovery and worsen outcomes 3
• Premature discontinuation of insulin therapy before complete resolution of ketosis can lead to recurrence of DKA 3
• Abrupt discontinuation of intravenous insulin coupled with a delayed onset of subcutaneous insulin can lead to poor glycemic control 4
• Cerebral edema is a rare but frequently fatal complication of DKA, occurring in 0.7-1.0% of children with DKA 1
• Failure to identify or treat the underlying cause of DKA can lead to treatment failure 3

Discharge Planning and Prevention

• Develop a structured discharge plan tailored to the individual patient to reduce length of hospital stay and readmission rates 3
• Provide education on the recognition, prevention, and management of DKA 3
• Ensure patients have appropriate medications, supplies, and prescriptions at discharge to avoid dangerous gaps in care 3
• Schedule follow-up appointments prior to discharge to increase the likelihood that patients will attend 3