What is the treatment protocol for Diabetic Ketoacidosis (DKA), including dosages and duration?

Treatment Protocol for Diabetic Ketoacidosis (DKA)

The treatment of diabetic ketoacidosis requires aggressive fluid resuscitation with isotonic saline at 15-20 mL/kg/hour, continuous intravenous insulin at 0.1 units/kg/hour, and careful electrolyte replacement, particularly potassium, until resolution of ketoacidosis. 1

Initial Assessment and Management

• Perform comprehensive laboratory evaluation including plasma glucose, blood urea nitrogen/creatinine, serum ketones, electrolytes, osmolality, urinalysis, urine ketones, arterial blood gases, complete blood count, and electrocardiogram 2
• Obtain bacterial cultures of urine, blood, and throat if infection is suspected, as infection is a common precipitating factor 2
• Chest X-ray should be obtained if clinically indicated 2

Fluid Resuscitation Protocol

• Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour (approximately 1-1.5 L in average adult) during the first hour 3
• Subsequent fluid choice depends on hydration state, serum electrolytes, and urinary output 3:
  • If corrected serum sodium is normal or elevated: use 0.45% NaCl at 4-14 mL/kg/hour
  • If corrected serum sodium is low: continue 0.9% NaCl at 4-14 mL/kg/hour
• Total fluid replacement should correct estimated deficits within 24 hours 3
• Monitor for fluid overload in patients with renal or cardiac compromise 3

Insulin Therapy

• Start with an IV bolus of regular insulin at 0.1 units/kg followed by continuous IV infusion at 0.1 units/kg/hour 1, 4
• Continue insulin infusion until resolution of ketoacidosis (pH ≥7.3, bicarbonate ≥18 mEq/L, and anion gap ≤12 mEq/L), regardless of glucose levels 1
• When blood glucose falls below 200-250 mg/dL, add dextrose to IV fluids to prevent hypoglycemia while continuing insulin infusion to clear ketones 3
• Once DKA resolves and the patient can eat, transition to subcutaneous insulin by administering basal insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia 3, 1

Electrolyte Management

• Include 20-30 mEq/L potassium (2/3 KCl and 1/3 KPO₄) in IV fluids once renal function is assured and serum potassium is known 3
• Guidelines for potassium replacement 5:
  • If serum K⁺ <3.3 mEq/L: Hold insulin and give 20-30 mEq/hr potassium until K⁺ >3.3 mEq/L
  • If serum K⁺ 3.3-5.3 mEq/L: Give 20-30 mEq potassium in each liter of IV fluid
  • If serum K⁺ >5.3 mEq/L: Do not give potassium but check levels frequently
• Do not exceed administration rates of 10 mEq/hour or 200 mEq for a 24-hour period if serum potassium is >2.5 mEq/L 5

Monitoring During Treatment

• Check blood glucose every 1-2 hours until stable 1
• Measure serum electrolytes, glucose, BUN, creatinine, osmolality, and venous pH every 2-4 hours 3, 2
• Monitor potassium levels closely as insulin therapy lowers serum potassium 1
• Follow venous pH and anion gap to monitor resolution of acidosis 2

Resolution Criteria for DKA

• Blood glucose <200 mg/dL 2
• Serum bicarbonate ≥18 mEq/L 2
• Venous pH >7.3 2
• Anion gap ≤12 mEq/L 2

Special Considerations

• Bicarbonate therapy is generally not recommended for DKA management 3
• Consider bicarbonate only if pH <6.9, administered as an infusion rather than bolus 6
• For patients with mild to moderate DKA, subcutaneous rapid-acting insulin may be an alternative to IV insulin when combined with aggressive fluid management 3, 7
• Early initiation of oral nutrition when the patient is able to eat has been shown to reduce ICU and hospital length of stay 6

Common Pitfalls to Avoid

• Discontinuing insulin therapy prematurely before ketoacidosis resolves can lead to recurrence 2
• Inadequate monitoring of electrolytes, particularly potassium, during treatment can lead to complications 2
• Relying solely on blood glucose levels to guide insulin therapy - continue insulin until ketoacidosis resolves 1
• Failing to identify and treat the underlying precipitating cause of DKA 3
• Rapid correction of hyperglycemia can lead to cerebral edema, especially in pediatric patients 6

Transition to Subcutaneous Insulin and Discharge Planning

• Start a multiple-dose insulin regimen using a combination of short/rapid-acting and intermediate/long-acting insulin 1
• Administer basal insulin 2-4 hours before stopping IV insulin infusion 3
• Provide education on recognition, prevention, and management of DKA to prevent recurrence 3
• Address the precipitating cause and develop a plan to prevent future episodes 8