What are the immediate management steps for diabetic ketoacidosis (DKA)?

Immediate Management of Diabetic Ketoacidosis (DKA)

The immediate management of DKA requires aggressive fluid resuscitation with isotonic saline 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, and careful electrolyte monitoring and replacement, particularly potassium. 1, 2

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
• 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
• Direct measurement of β-hydroxybutyrate in blood is the preferred method for monitoring DKA, as it more accurately reflects the severity of ketosis 2

Fluid Therapy

• Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour during the first hour to restore intravascular volume and tissue perfusion 1, 2
• Continue fluid replacement to correct estimated deficits within the first 24 hours, with a goal of administering 1.5 to 2 times the 24-hour maintenance requirements 1
• For mild DKA, 1.5 times the 24-hour maintenance requirements (5 mL/kg/h) will accomplish smooth rehydration; do not exceed twice the maintenance requirement 2
• Monitor fluid input/output, hemodynamic parameters, and clinical examination to assess progress with fluid replacement 2

Insulin Therapy

• Start continuous intravenous regular insulin infusion at 0.1 units/kg/hour without an initial bolus 1, 2
• 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 of 50-75 mg/hour is achieved 1, 2
• Target blood glucose levels of 100-180 mg/dL during treatment 2
• Continue intravenous insulin until DKA resolves (glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L) 1, 2

Electrolyte Management

• Monitor potassium levels closely as insulin therapy and correction of acidosis can cause hypokalemia 1, 2
• Include 20-30 mEq/L potassium in IV fluids once renal function is assured and serum potassium is <5.3 mEq/L 1
• If significant hypokalemia is present initially (<3.3 mEq/L), delay insulin treatment until potassium concentration is restored to avoid arrhythmias, cardiac arrest, and respiratory muscle weakness 2
• Bicarbonate therapy is generally not recommended in DKA patients with pH >7.0 2
• For adult patients with pH <6.9, consider administering 100 mmol sodium bicarbonate in 400 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, 2
• Follow venous pH and anion gap to monitor resolution of acidosis 1
• Monitor for complications, particularly electrolyte imbalances that can trigger cardiac arrhythmias 2

Transition to Subcutaneous Insulin

• Transition to subcutaneous insulin when DKA resolves (glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L) 1, 2
• Administer basal insulin 2-4 hours before stopping the IV insulin infusion to prevent recurrence of ketoacidosis 3, 1
• Recent studies suggest that administration of a low dose of basal insulin analog in addition to intravenous insulin infusion may prevent rebound hyperglycemia 3, 2

Identification and Treatment of Precipitating Causes

• Treat any correctable underlying cause of DKA, such as sepsis, myocardial infarction, or stroke 3
• Obtain bacterial cultures of urine, blood, and other sites as needed and administer appropriate antibiotics if infection is suspected 2
• Discontinue SGLT2 inhibitors 3-4 days before surgery to prevent DKA 3, 1

Prevention of Complications

• Cerebral edema is a rare but potentially fatal complication of DKA, particularly in children 2, 4
• To prevent cerebral edema, follow recommendations for gradual correction of glucose and osmolality 2
• Avoid rapid overcorrection of hyperglycemia with fluids and insulin 5
• Risk factors for cerebral edema include severity of acidosis, greater hypocapnia, higher blood urea nitrogen concentration at presentation, and treatment with bicarbonate 4