What is the recommended management for diabetic ketoacidosis (DKA)?

Management of Diabetic Ketoacidosis (DKA)

The management of diabetic ketoacidosis requires aggressive fluid resuscitation with isotonic saline, continuous insulin therapy until resolution of ketoacidosis, careful electrolyte monitoring and replacement, and identification and treatment of precipitating factors. 1

Initial Assessment and Diagnosis

• Perform laboratory evaluation including plasma glucose, blood urea nitrogen/creatinine, serum ketones, electrolytes, osmolality, urinalysis, arterial blood gases, and complete blood count to confirm DKA diagnosis 2
• Direct measurement of β-hydroxybutyrate in blood is the preferred method for monitoring DKA 1
• Identify and treat precipitating factors such as infection, myocardial infarction, or stroke 1
• Obtain bacterial cultures and administer appropriate antibiotics if infection is suspected 2

Fluid Resuscitation

• Begin aggressive fluid management using isotonic saline (0.9% NaCl) at a rate of 15-20 mL/kg/hour for the first hour to restore circulatory volume and tissue perfusion 1, 2
• Total fluid replacement should be approximately 1.5 times the 24-hour maintenance requirements 2
• Continue fluid replacement to correct dehydration, which is a key component of DKA management 1

Insulin Therapy

• For moderate to severe DKA, administer continuous intravenous regular insulin infusion starting with an IV bolus of 0.1 units/kg followed by continuous infusion at 0.1 units/kg/hour 2
• For mild DKA in stable patients, subcutaneous rapid-acting insulin analogs combined with aggressive fluid management can be as effective as intravenous insulin 1
• Continue insulin therapy until resolution of ketoacidosis (pH >7.3, serum bicarbonate ≥18 mEq/L, and anion gap ≤12 mEq/L) 1
• Do not discontinue insulin therapy prematurely when glucose levels fall below 200-250 mg/dL; instead, add dextrose to the hydrating solution while continuing insulin infusion 1

Electrolyte Management

• Monitor potassium levels closely, as insulin administration can cause hypokalemia 1
• Include 20-30 mEq/L potassium in the infusion once renal function is assured to maintain serum K+ between 4-5 mmol/L 1, 2
• Monitor serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH every 2-4 hours 1, 2

Monitoring During Treatment

• Check blood glucose every 2-4 hours 2
• Follow venous pH (typically 0.03 units lower than arterial pH) and anion gap to monitor resolution of acidosis 1
• DKA resolution requires glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L 1
• Note that ketonemia typically takes longer to clear than hyperglycemia 1

Transition to Subcutaneous Insulin

• When DKA resolves and the patient can eat, start a multiple-dose insulin schedule using a combination of short/rapid-acting and intermediate/long-acting insulin 2
• Administer basal insulin 2-4 hours before stopping the intravenous insulin to prevent recurrence of ketoacidosis 1, 2

Special Considerations

Euglycemic DKA

• For euglycemic DKA (blood glucose <250 mg/dL with ketoacidosis), the same principles of management apply with careful attention to providing adequate carbohydrates alongside insulin 3
• Inadequate carbohydrate administration alongside insulin in euglycemic DKA can perpetuate ketosis 3

Complications and Prevention

• Hypoglycemia is a frequent adverse event in insulin users and can be brought about by missing meals, taking too much insulin, or exercising more than usual 4
• Cerebral edema is a rare but severe complication that occurs predominantly in children and can be prevented by avoiding rapid overcorrection of hyperglycemia 5

Common Pitfalls to Avoid

• Premature termination of insulin therapy before complete resolution of ketosis can lead to recurrence of DKA 1
• Inadequate fluid resuscitation can worsen DKA 1
• Interruption of insulin infusion when glucose levels fall is a common cause of persistent or worsening ketoacidosis 1
• Bicarbonate administration is generally not recommended for DKA patients 1, 3
• Insufficient timing or dosing of subcutaneous insulin before discontinuation of intravenous insulin can lead to recurrence of DKA 6