What is the management and treatment of diabetic ketoacidosis (DKA)?

Management of Diabetic Ketoacidosis (DKA)

The management of diabetic ketoacidosis requires aggressive fluid resuscitation, insulin therapy, electrolyte replacement, and treatment of underlying precipitating factors to reduce morbidity and mortality. 1, 2

Diagnostic Criteria

• DKA is characterized by the triad of hyperglycemia (blood glucose >250 mg/dL), ketosis (moderate ketonuria or ketonemia), and metabolic acidosis (serum bicarbonate <15-18 mmol/L with increased anion gap) 3, 1
• Initial laboratory evaluation should include 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 3
• Direct measurement of β-hydroxybutyrate in blood is preferred over nitroprusside method for diagnosing and monitoring DKA 1
• Bacterial cultures (urine, blood, throat) should be obtained if infection is suspected as a precipitating factor 3, 1

Initial Management

Fluid Therapy

• Begin aggressive fluid resuscitation with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour (1-1.5 liters in average adult) during the first hour to expand intravascular volume and restore renal perfusion 3, 2
• Subsequent fluid choice depends on hydration status, serum electrolyte levels, and urinary output 3
• Generally, 0.45% NaCl at 4-14 mL/kg/hour is appropriate if corrected serum sodium is normal or elevated; 0.9% NaCl at similar rate if corrected serum sodium is low 3, 1
• Fluid replacement should aim to correct estimated deficits within 24 hours 1, 2

Insulin Therapy

• Administer continuous intravenous insulin at 0.1 units/kg/hour until resolution of ketoacidosis, regardless of glucose levels 2
• If plasma glucose doesn't fall by 50 mg/dL from initial value in first hour, check hydration status; if acceptable, double insulin infusion hourly until steady glucose decline of 50-75 mg/hour is achieved 1, 2
• When glucose reaches 200-250 mg/dL, add dextrose to IV fluids while continuing insulin infusion to resolve ketosis 2, 4
• Continue insulin infusion until resolution of ketoacidosis (pH >7.3, serum bicarbonate ≥18 mEq/L, and anion gap ≤12 mEq/L) 1, 2

Electrolyte Management

• Once renal function is assured, include 20-30 mEq/L potassium (2/3 KCl and 1/3 KPO₄) in IV fluids until patient can tolerate oral supplementation 3, 1
• Monitor potassium levels closely, as insulin administration can cause hypokalemia; maintain serum K⁺ between 4-5 mmol/L 2, 4
• Bicarbonate administration is generally not recommended for DKA patients with pH >7.0 3, 2

Monitoring During Treatment

• Draw blood every 2-4 hours to measure electrolytes, glucose, BUN, creatinine, osmolality, and venous pH 1, 2
• Follow venous pH and anion gap to monitor resolution of acidosis 1
• Remember that ketonemia typically takes longer to clear than hyperglycemia 1, 2

Resolution Criteria

• DKA resolution requires glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L 1, 2
• Once DKA is resolving and patient can eat, transition to multiple-dose insulin schedule using combination of short/rapid-acting and intermediate/long-acting insulin 2

Transition to Subcutaneous Insulin

• When transitioning to subcutaneous insulin, administer basal insulin 2-4 hours before stopping IV insulin to prevent recurrence of ketoacidosis 3, 2
• For uncomplicated DKA, subcutaneous insulin combined with aggressive fluid management may be used in emergency department or step-down units 3

Treatment of Precipitating Factors

• Identify and treat any underlying cause such as infection, myocardial infarction, or stroke 3, 5
• For patients on SGLT2 inhibitors who develop euglycemic DKA, continue insulin therapy with dextrose despite normal or near-normal glucose levels 4, 6

Special Considerations

• For pregnant patients, children, or those with chronic kidney disease, management may require modifications based on individual needs 6, 7
• Thromboprophylaxis with enoxaparin should be considered due to hypercoagulable state associated with DKA 2
• For patients on glucocorticoid therapy, insulin requirements may be significantly higher 3

Common Pitfalls to Avoid

• Premature discontinuation of insulin therapy before complete resolution of ketosis 2, 4
• Relying solely on urine ketones for diagnosis or monitoring response to treatment 1, 4
• Inadequate monitoring of electrolytes, particularly potassium 2, 8
• Excessive fluid resuscitation, especially in children, which may increase risk of cerebral edema 7, 8
• Interrupting insulin infusion when glucose levels fall without adding dextrose to IV fluids 2, 4