What is the primary recommendation for managing Diabetic Ketoacidosis (DKA) as investigated in the SCOPE DKA trial?

Primary Recommendations for Managing Diabetic Ketoacidosis (DKA) Based on the SCOPE DKA Trial

The primary recommendation for managing Diabetic Ketoacidosis (DKA) is intravenous insulin therapy, with regular insulin administered as a continuous intravenous infusion at 0.1 U/kg/h following an initial bolus of 0.15 U/kg. 1

Initial Assessment and Diagnosis

• DKA diagnosis requires all three criteria: elevated blood glucose, presence of ketones, and metabolic acidosis 2
• Initial laboratory evaluation should include plasma glucose, blood urea nitrogen, creatinine, serum ketones, electrolytes with calculated anion gap, osmolality, urinalysis, arterial blood gases, and complete blood count 1
• Direct measurement of β-hydroxybutyrate in blood is the preferred method for monitoring DKA 1, 3
• Continuous cardiac monitoring is crucial in severe DKA to detect arrhythmias early 1

Fluid Therapy

• Begin with balanced electrolyte solutions at a rate of 15-20 mL/kg/h during the first hour to restore circulatory volume and tissue perfusion 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 1
• Continue fluid replacement to correct estimated deficits within the first 24 hours, with careful monitoring to prevent rapid changes in serum osmolality 1

Insulin Therapy

• Administer an intravenous bolus of regular insulin at 0.15 U/kg body weight, followed by a continuous infusion at 0.1 U/kg/h 1
• If plasma glucose does not fall by 50 mg/dL from the initial value in the first hour, double the insulin infusion every hour until a steady glucose decline between 50-75 mg/h is achieved 1
• When glucose falls below 200-250 mg/dL, add dextrose to the hydrating solution while continuing insulin infusion to prevent premature termination of insulin therapy 3
• For mild DKA, subcutaneous insulin may be considered as an alternative to IV insulin 4

Electrolyte Management

• Monitor potassium levels closely as total body potassium deficits are common despite potentially normal or elevated initial serum levels due to acidosis 1
• Begin potassium replacement after serum levels fall below 5.5 mEq/L, assuming adequate urine output 1
• Add 20-30 mEq potassium (2/3 KCl and 1/3 KPO4) in each liter of infusion fluid to maintain serum potassium concentration within 4-5 mEq/L 1
• If significant hypokalemia is present initially, delay insulin treatment until potassium concentration is restored to >3.3 mEq/L to avoid arrhythmias, cardiac arrest, and respiratory muscle weakness 5, 1

Bicarbonate Therapy

• Bicarbonate therapy is generally not recommended in DKA patients with pH >7.0, as studies have failed to show beneficial effects on clinical outcomes 5, 1
• For adult patients with pH <6.9, administer 100 mmol sodium bicarbonate in 400 mL sterile water at 200 mL/h 5, 1
• For patients with pH 6.9-7.0, administer 50 mmol sodium bicarbonate in 200 mL sterile water at 200 mL/h 5, 1

Phosphate Replacement

• Routine phosphate replacement is not recommended as studies have failed to show beneficial effects on clinical outcomes in DKA 5, 1
• Consider phosphate replacement only in patients with cardiac dysfunction, anemia, respiratory depression, or serum phosphate <1.0 mg/dL 5, 1

Monitoring and Resolution Parameters

• Draw blood every 2-4 hours to determine serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH 1
• DKA resolution requires glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L 1, 3
• Venous pH (typically 0.03 units lower than arterial pH) and anion gap can be followed to monitor resolution of acidosis 1

Transition from IV to Subcutaneous Insulin

• When DKA is resolved and the patient can eat, transition to a multiple-dose regimen using a combination of short/rapid-acting and intermediate/long-acting insulin 1
• Administer basal insulin 2-4 hours before stopping the intravenous insulin to prevent recurrence of ketoacidosis and rebound hyperglycemia 1, 3
• For newly diagnosed patients, initiate a multidose regimen of short- and intermediate/long-acting insulin at approximately 0.5-1.0 units/kg/day 1

Common Pitfalls to Avoid

• Premature termination of insulin therapy before complete resolution of ketosis can lead to recurrence of DKA 3
• Inadequate fluid resuscitation can worsen DKA 3
• Interruption of insulin infusion when glucose levels fall is a common cause of persistent or worsening ketoacidosis 3
• Cerebral edema is a rare but frequently fatal complication of DKA, particularly in children; follow recommendations for gradual correction of glucose and osmolality 1

Prevention and Discharge Planning

• Identify and treat precipitating factors such as infection, myocardial infarction, or stroke 3, 6
• SGLT2 inhibitors should be discontinued 3-4 days before surgery to prevent DKA 1, 6
• A structured discharge plan should be tailored to the individual to reduce length of hospital stay and readmission rates 1, 3
• Include education on the recognition, prevention, and management of DKA for all individuals affected by or at high risk for these events 1