Treatment of Diabetic Ketoacidosis (DKA)
Begin immediate treatment with isotonic fluid resuscitation at 15-20 mL/kg/h during the first hour using balanced electrolyte solutions, followed by continuous intravenous regular insulin at 0.1 U/kg/h (after confirming potassium >3.3 mEq/L), while closely monitoring electrolytes and glucose to prevent life-threatening complications. 1, 2
Initial Assessment and Laboratory Evaluation
Obtain the following tests immediately to confirm diagnosis and guide treatment 1, 2:
- Plasma glucose, serum ketones (β-hydroxybutyrate preferred), arterial blood gases
- Electrolytes with calculated anion gap, serum osmolality
- Blood urea nitrogen, creatinine
- Complete blood count with differential
- Urinalysis
- Electrocardiogram with continuous cardiac monitoring 2
DKA is diagnosed by the presence of metabolic acidosis (pH <7.3, bicarbonate <18 mEq/L, anion gap >10 mEq/L) with elevated ketones, though hyperglycemia has been de-emphasized due to increasing euglycemic DKA. 3
Fluid Resuscitation
Start with balanced electrolyte solutions rather than 0.9% saline at 15-20 mL/kg/h during the first hour to restore circulatory volume and tissue perfusion. 1, 2 This aggressive initial fluid replacement is critical as DKA patients typically have significant volume depletion.
Continue fluid replacement to correct estimated deficits within 24 hours, ensuring the induced change in serum osmolality does not exceed 3 mOsm/kg/h to prevent cerebral edema 2. Monitor fluid input/output and hemodynamic parameters closely 1.
Insulin Therapy
Administer intravenous regular insulin at 0.1 U/kg/h without an initial bolus if cardiac compromise is present, or with a 0.15 U/kg bolus followed by 0.1 U/kg/h infusion in stable patients. 1, 2 Do not start insulin until potassium is confirmed >3.3 mEq/L to avoid life-threatening arrhythmias 2.
If plasma glucose does not fall by 50 mg/dL in the first hour, double the insulin infusion hourly until achieving a steady decline of 50-75 mg/dL/hour 2. When blood glucose reaches 250 mg/dL, add dextrose to IV fluids while continuing insulin infusion to clear ketones 1.
Critical pitfall: Never discontinue IV insulin prematurely—ketosis may persist even after glucose normalization. 1 When transitioning to subcutaneous insulin, administer basal insulin 2-4 hours before stopping the IV infusion to prevent rebound ketoacidosis 4, 1, 2.
Electrolyte Management
Potassium
Monitor potassium closely as total body deficits are common despite potentially normal or elevated initial levels due to acidosis. 1, 2 Once renal function is confirmed and potassium falls below 5.5 mEq/L, add 20-40 mEq/L potassium to each liter of IV fluid 1, 2.
Add potassium as 2/3 KCl and 1/3 KPO4 to maintain serum levels between 4-5 mEq/L 2. If severe hypokalemia (<3.3 mEq/L) is present initially, delay insulin treatment until potassium is restored to prevent cardiac arrhythmias, cardiac arrest, and respiratory muscle weakness 2.
Bicarbonate
Bicarbonate therapy is not recommended for pH >7.0 as studies show no benefit in resolution of acidosis or clinical outcomes. 4, 2 For pH <6.9, consider 100 mmol sodium bicarbonate in 400 mL sterile water at 200 mL/h; for pH 6.9-7.0, give 50 mmol in 200 mL at 200 mL/h 2.
Phosphate
Routine phosphate replacement has not shown beneficial effects on clinical outcomes 2. Consider replacement only in patients with cardiac dysfunction, anemia, respiratory depression, or serum phosphate <1.0 mg/dL 2.
Monitoring Protocol
Draw blood every 2-4 hours for serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH 1, 2. Check blood glucose every 1-2 hours until stable, then every 4 hours 4. Target blood glucose of 100-180 mg/dL during treatment 1.
Monitor continuously for complications, particularly electrolyte imbalances triggering cardiac arrhythmias 2. Watch for signs of cerebral edema (rare but potentially fatal, occurring in 0.7-1.0% of children with DKA) 2.
Resolution Criteria
DKA is resolved when all of the following are met: 4, 2
- Glucose <200 mg/dL
- Serum bicarbonate ≥18 mEq/L
- Venous pH >7.3
- Anion gap ≤12 mEq/L
Treatment of Precipitating Causes
Obtain bacterial cultures of urine, blood, and other sites as indicated 2. Administer appropriate antibiotics if infection is suspected—infection and non-adherence to insulin are the most common precipitating factors 4, 5.
Important consideration: SGLT2 inhibitors modestly increase DKA risk and should be discontinued 3-4 days before surgery. 4, 2 Pregnant individuals may present with euglycemic DKA and require immediate medical attention due to significant feto-maternal harm risk 4.
Mild DKA Management
For uncomplicated mild DKA in hemodynamically stable patients who can tolerate oral hydration, subcutaneous rapid-acting insulin analogs combined with aggressive fluid management show no significant difference in outcomes compared to IV insulin 4. This approach may be safer and more cost-effective when appropriate nurse training and frequent monitoring are available 4.
Discharge Planning
Develop a structured discharge plan including 4, 2:
- Identification of outpatient diabetes care provider
- Education on recognition, prevention, and treatment of hyperglycemia and hypoglycemia
- Instruction on insulin administration and blood glucose monitoring
- Referral to registered dietitian nutritionist
- Scheduled follow-up appointments before discharge
Provide adequate durable medical equipment, medications, supplies, and prescriptions to avoid dangerous gaps in care 4. Access to continuous glucose monitoring may decrease DKA recurrence risk 4.