What are the guidelines for managing diabetic ketoacidosis in terms of blood sugar levels in mmol/L?

Management of Diabetic Ketoacidosis: Blood Sugar Targets in mmol/L

For patients with diabetic ketoacidosis (DKA), the target blood glucose range during treatment should be 7.8-10.0 mmol/L (140-180 mg/dL) for most patients, with continuous insulin infusion as the preferred treatment method. 1

Initial Assessment and Diagnosis

• DKA is characterized by hyperglycemia (blood glucose >11.1 mmol/L or 200 mg/dL), metabolic acidosis (venous pH <7.3 or bicarbonate <15 mEq/L), and ketosis (ketonemia >3 mmol/L) 1
• Euglycemic DKA can occur with blood glucose <13.9 mmol/L (250 mg/dL), particularly in patients on SGLT-2 inhibitors, requiring modified treatment approaches 2, 3
• Assess for precipitating factors including infections, new diagnosis of diabetes, or non-adherence to insulin therapy 4

Treatment Protocol

Fluid Resuscitation

• Begin with isotonic saline (0.9% NaCl) at 500 mL/hour for the first 2-3 liters to replace extracellular fluid deficit 5
• After initial resuscitation, transition to 5% glucose in 0.45% saline when blood glucose falls below 13.9 mmol/L (250 mg/dL) 1, 5

Insulin Therapy

• Continuous intravenous insulin infusion is the standard of care for moderate to severe DKA 1
• Initial dosing: 0.5 units/hour, adjusted to maintain blood glucose in target range 6
• Continue insulin infusion until metabolic acidosis resolves (pH >7.3, bicarbonate >15 mEq/L) 1
• Subcutaneous insulin may be considered for mild DKA cases in settings with limited ICU availability 7

Blood Glucose Monitoring and Targets

• Monitor blood glucose every 1-2 hours during active treatment 5
• Target blood glucose range: 7.8-10.0 mmol/L (140-180 mg/dL) 1
• Avoid targeting lower glucose levels (<6.1 mmol/L or 110 mg/dL) due to increased risk of hypoglycemia 1
• For selected ICU patients with extensive nursing support, a lower target of 6.1-7.8 mmol/L (110-140 mg/dL) may be considered 1

Electrolyte Management

• Monitor potassium levels every 2-3 hours during initial treatment 5
• Potassium replacement is often required as insulin therapy drives potassium into cells 1
• Hypokalaemia occurs in approximately 50% of DKA cases during treatment and is associated with increased mortality 1

Transition from IV to Subcutaneous Insulin

• Administer subcutaneous basal insulin 2-4 hours before discontinuing IV insulin to prevent rebound hyperglycemia 1
• Once the patient can tolerate oral intake, metabolic acidosis has resolved, and blood glucose is stable, transition to subcutaneous insulin regimen 1
• Continue monitoring blood glucose levels every 3-4 hours after transition 1

Special Considerations

• For euglycemic DKA (glucose <13.9 mmol/L or 250 mg/dL), administer glucose-containing IV fluids while continuing insulin therapy to suppress ketogenesis 3
• In pediatric patients with DKA, careful monitoring for cerebral edema is essential 1
• For pregnant patients with DKA, more aggressive monitoring and treatment may be required with tighter glucose targets 1

Discharge Planning

• Provide comprehensive diabetes education before discharge 4
• Establish appropriate insulin regimen and self-monitoring protocol 1
• Schedule follow-up within 1-2 weeks to assess glycemic control 1

By following these guidelines for managing blood glucose levels in DKA, clinicians can effectively treat this serious complication while minimizing the risks of hypoglycemia and other treatment-related complications.