What is the management of diabetic ketoacidosis?

Management of Diabetic Ketoacidosis (DKA)

The management of diabetic ketoacidosis requires immediate intervention with fluid resuscitation, insulin therapy, electrolyte replacement, and identification of precipitating causes to restore circulatory volume, resolve hyperglycemia, correct electrolyte imbalances, and treat underlying conditions. 1, 2

Initial Assessment and Diagnosis

• 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 1
• Diagnostic criteria include 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 preferred over nitroprusside method which only measures acetoacetic acid and acetone 2
• Obtain bacterial cultures (urine, blood, throat) if infection is suspected 1

Fluid Therapy

• Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour during the first hour to restore intravascular volume and renal perfusion 1
• Total fluid replacement should be approximately 1.5 times the 24-hour maintenance requirements 1
• Subsequent fluid choice depends on hydration status, serum electrolyte levels, and urine output 1
• When serum glucose reaches 250 mg/dL, add dextrose to IV fluids to prevent hypoglycemia while continuing insulin to clear ketosis 1, 2

Insulin Therapy

• Start continuous intravenous regular insulin infusion at 0.1 units/kg/hour without an initial bolus for moderate to severe DKA 1
• 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 1
• When serum glucose reaches 250 mg/dL, decrease insulin infusion to 0.05-0.1 units/kg/hour and add dextrose to IV fluids 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) 2

Electrolyte Management

• Monitor potassium levels closely as insulin therapy and correction of acidosis can cause hypokalemia 1
• Include 20-30 mEq/L potassium in IV fluids once renal function is assured and serum potassium is <5.3 mEq/L 1
• Maintain serum potassium between 4-5 mmol/L throughout treatment 1
• Consider phosphate replacement only in patients with cardiac dysfunction, anemia, respiratory depression, or serum phosphate <1.0 mg/dL 2

Bicarbonate Administration

• Bicarbonate administration is generally not recommended for DKA patients with pH >6.9 1, 3
• For adult patients with pH <6.9, administer 100 mmol sodium bicarbonate in 400 mL sterile water at 200 mL/h 2
• For patients with pH 6.9-7.0, administer 50 mmol sodium bicarbonate in 200 mL sterile water at 200 mL/h 2

Monitoring During Treatment

• Check blood glucose every 1-2 hours 1
• Draw blood every 2-4 hours to determine serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH 1
• Follow venous pH and anion gap to monitor resolution of acidosis 1

Transition to Subcutaneous Insulin

• When DKA resolves, transition to subcutaneous insulin 1
• Administer basal insulin 2-4 hours before stopping the IV insulin infusion to prevent recurrence of ketoacidosis 1, 4
• For newly diagnosed patients, initiate a multidose regimen of short- and intermediate/long-acting insulin at approximately 0.5-1.0 units/kg/day 2

Common Pitfalls to Avoid

• Premature termination of insulin therapy before complete resolution of ketosis can lead to recurrence of DKA 1
• Inadequate monitoring of potassium levels during insulin therapy can cause dangerous hypokalemia 1
• Interruption of insulin infusion when glucose levels fall without adding dextrose is a common cause of persistent or worsening ketoacidosis 1
• Relying on nitroprusside method to measure ketones is misleading as it only measures acetoacetic acid and acetone, not β-hydroxybutyrate 1
• Bicarbonate administration in patients with pH >6.9 has not shown beneficial effects on clinical outcomes 2

Discharge Planning and Prevention

• A structured discharge plan tailored to the individual patient can reduce length of hospital stay and readmission rates 4
• Include education on recognition, prevention, and management of DKA for all individuals at risk 2
• Ensure follow-up appointments are scheduled prior to discharge to increase attendance likelihood 4