What is the management for acute diabetic ketoacidosis?

Management of Acute Diabetic Ketoacidosis

The management of acute diabetic ketoacidosis requires immediate fluid resuscitation with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour during the first hour, followed by continuous intravenous regular insulin at 0.1 units/kg/hour without an initial bolus, along with careful electrolyte monitoring and replacement until resolution of ketoacidosis. 1, 2, 3

Initial Assessment and Diagnosis

• Perform comprehensive laboratory evaluation including 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, 3
• Diagnostic criteria for DKA include plasma glucose >250 mg/dL, arterial pH <7.30, serum bicarbonate <18 mEq/L, and positive serum and urine ketones 1, 2
• Obtain bacterial cultures (urine, blood, throat) if infection is suspected and administer appropriate antibiotics 1
• Direct measurement of β-hydroxybutyrate in blood is preferred over nitroprusside method, which only measures acetoacetic acid and acetone 4, 3

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, 2, 3
• 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 (5% dextrose with 0.45-0.75% NaCl) to maintain adequate glucose levels while continuing insulin therapy to clear ketosis 4, 3
• Total fluid replacement should be approximately 1.5 times the 24-hour maintenance requirements 3
• Recent evidence suggests lactated Ringer's solution may offer faster resolution of high anion gap metabolic acidosis compared to normal saline 5

Insulin Therapy

• Start continuous intravenous regular insulin infusion at 0.1 units/kg/hour without an initial bolus 1, 2, 3
• 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 2, 3
• When serum glucose reaches 250 mg/dL, decrease insulin infusion to 0.05-0.1 units/kg/hour and add dextrose to IV fluids to prevent hypoglycemia while continuing insulin to clear ketosis 3
• Never interrupt insulin infusion when glucose levels fall; instead, add dextrose to prevent hypoglycemia while continuing insulin to clear ketosis 4, 6

Electrolyte Management

• Monitor potassium levels closely as insulin therapy and correction of acidosis can cause hypokalemia 1, 2, 3
• 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 <5.3 mEq/L 4, 2
• Maintain serum potassium between 4-5 mmol/L throughout treatment 4, 3
• Bicarbonate administration is generally not recommended for patients with pH >6.9 4, 3

Monitoring During Treatment

• Check blood glucose every 1-2 hours 2, 3
• Draw blood every 2-4 hours to determine serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH 1, 2
• Follow venous pH and anion gap to monitor resolution of acidosis 2, 3

Resolution Parameters and Transition to Subcutaneous Insulin

• DKA resolution requires: glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L 1, 2, 3
• When transitioning to subcutaneous insulin, administer basal insulin 2-4 hours before stopping the intravenous insulin to prevent recurrence of ketoacidosis 1, 2, 3
• Administration of a low dose of basal insulin analog in addition to intravenous insulin infusion may prevent rebound hyperglycemia 2

Common Pitfalls to Avoid

• Premature termination of insulin therapy before complete resolution of ketosis can lead to recurrence of DKA 3, 6
• Inadequate monitoring and replacement of electrolytes, particularly potassium 4, 3
• Interruption of insulin infusion when glucose levels fall without adding dextrose 4, 6
• Relying solely on nitroprusside method to measure ketones, which doesn't detect β-hydroxybutyrate, the predominant ketone body in DKA 4, 3
• Insufficient timing or dosing of subcutaneous insulin before discontinuation of intravenous insulin 6

Special Considerations

• For euglycemic DKA (blood glucose <250 mg/dL), add dextrose-containing fluids earlier in treatment while continuing insulin therapy to clear ketosis 4
• During acute illness, individuals with type 1 diabetes should continue insulin and may require additional insulin to prevent ketoacidosis 1
• Patients on SGLT2 inhibitors may develop euglycemic DKA, which requires the same insulin and fluid management as traditional DKA, with earlier addition of dextrose 2