What is the treatment for severe acidosis with diabetic ketoacidosis (DKA)?

Treatment of Severe Acidosis with Diabetic Ketoacidosis (DKA)

The treatment for severe acidosis in diabetic ketoacidosis requires aggressive fluid resuscitation, intravenous insulin therapy, electrolyte management, and identification and treatment of precipitating factors, with bicarbonate therapy generally not recommended except in specific circumstances.

Initial Assessment and Management

• Perform careful clinical and laboratory assessment including plasma glucose, blood urea nitrogen/creatinine, serum ketones, electrolytes with calculated anion gap, osmolality, urinalysis, urine ketones, arterial blood gases, and complete blood count 1, 2
• Identify and treat any precipitating factors such as infection, myocardial infarction, or stroke 1, 2
• Severity classification of DKA based on arterial pH:
  • Mild: pH 7.25-7.30
  • Moderate: pH 7.00-7.24
  • Severe: pH <7.00 3

Fluid Resuscitation

• Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg body weight/hour (1-1.5 liters in average adult) during the first hour to expand intravascular volume and restore renal perfusion 1, 2
• Continue fluid replacement with 0.45% NaCl at 4-14 mL/kg/hour if corrected serum sodium is normal or elevated; use 0.9% NaCl if corrected serum sodium is low 1, 2
• Total water deficit in DKA typically ranges from 6 liters (100 mL/kg) and should be replaced over 24-48 hours 1, 3

Insulin Therapy

• For severe DKA with pH <7.00, continuous intravenous insulin is the standard of care 1, 2
• Begin with an intravenous bolus of regular insulin at 0.15 units/kg body weight, followed by a continuous infusion at 0.1 unit/kg/hour 3, 4
• When glucose falls below 200-250 mg/dL, add dextrose to the hydrating solution while continuing insulin infusion to prevent hypoglycemia and ensure complete resolution of ketoacidosis 1, 2
• Continue insulin therapy until resolution of ketoacidosis (pH >7.3, serum bicarbonate ≥18 mEq/L, and anion gap ≤12 mEq/L) 2, 3

Electrolyte Management

• Monitor potassium levels closely as total body potassium is depleted despite potentially normal or elevated initial serum levels due to acidosis 1, 2
• Once renal function is assured, include 20-30 mEq/L potassium (2/3 KCl and 1/3 KPO₄) in the infusion when serum potassium falls below 5.5 mEq/L 1, 2
• In patients with relatively low plasma potassium levels (<3.3 mEq/L), temporarily delay insulin administration and first administer potassium chloride intravenously to bring plasma potassium close to 4 mmol/L to prevent cardiac arrhythmias 5, 6
• Target maintaining serum potassium between 4-5 mmol/L throughout treatment 2, 6

Bicarbonate Therapy

• Several studies have shown that bicarbonate administration in patients with DKA made no difference in resolution of acidosis or time to discharge, and its use is generally not recommended 1
• Consider bicarbonate therapy only in adult patients with severe acidemia (pH <7.20 and plasma bicarbonate <12 mmol/L) who are hemodynamically unstable or at risk for worsening acidemia 5, 6
• Bicarbonate should not be administered to children with DKA except if acidemia is very severe and hemodynamic instability is refractory to saline administration 5

Monitoring During Treatment

• Monitor blood glucose every 1-2 hours until stable 2, 3
• Draw blood every 2-4 hours to determine serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH 2, 3
• Monitor for complications, particularly electrolyte imbalances that can trigger cardiac arrhythmias 2, 6
• Direct measurement of β-hydroxybutyrate in blood is the preferred method for monitoring ketosis resolution 2, 3

Transition 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 1, 2
• Administer basal insulin 2-4 hours before stopping the intravenous insulin to prevent recurrence of ketoacidosis and rebound hyperglycemia 1, 2
• Recent studies suggest that administration of a low dose of basal insulin analog in addition to intravenous insulin infusion may prevent rebound hyperglycemia without increased risk of hypoglycemia 1

Common Pitfalls to Avoid

• Premature termination of insulin therapy before complete resolution of ketosis can lead to recurrence of DKA 2, 6
• Inadequate fluid resuscitation can worsen DKA and delay recovery 2, 6
• Interruption of insulin infusion when glucose levels fall is a common cause of persistent or worsening ketoacidosis; instead, add dextrose to the hydrating solution while continuing insulin 2, 4
• Failure to monitor and replace potassium can lead to life-threatening cardiac arrhythmias 2, 4
• Cerebral edema is a rare but severe complication, especially in children, that may be minimized by avoiding insulin bolus, excessive saline resuscitation, and rapid decrease in effective plasma osmolality 5, 7