What is the immediate treatment for a patient presenting with Diabetic Ketoacidosis (DKA)?

Immediate Treatment of Diabetic Ketoacidosis (DKA)

Begin aggressive fluid resuscitation with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour immediately, followed by continuous intravenous insulin infusion at 0.1 units/kg/hour, while simultaneously monitoring and replacing electrolytes, particularly potassium. 1, 2

Initial Resuscitation (First Hour)

Fluid Management

• Administer 0.9% normal saline at 15-20 mL/kg/hour to restore circulatory volume and tissue perfusion 3, 1
• This typically translates to 1-1.5 liters in the first hour for most adults 1
• After initial volume expansion, adjust fluid choice based on corrected serum sodium:
  • If corrected sodium is normal or elevated: use 0.45% NaCl at 4-14 mL/kg/hour 1
  • If corrected sodium is low: continue 0.9% NaCl at similar rate 1

Insulin Therapy

• Start continuous IV insulin infusion at 0.1 units/kg/hour once initial fluid resuscitation has begun 3, 1
• Do NOT delay insulin for potassium replacement unless K+ is <3.3 mEq/L 1
• If glucose does not fall by 50 mg/dL in the first hour, verify adequate hydration, then double the insulin infusion rate hourly until achieving a steady decline of 50-75 mg/dL per hour 1

Critical Electrolyte Management

• Check potassium immediately - this is the most dangerous electrolyte abnormality 1, 2
• Once potassium is >3.3 mEq/L and renal function is confirmed, add 20-30 mEq/L potassium to IV fluids (2/3 KCl and 1/3 KPO₄) 1
• Target serum potassium between 4-5 mmol/L throughout treatment 1, 4
• Insulin drives potassium intracellularly and can cause life-threatening hypokalemia 1

Ongoing Management (Hours 2-24)

Glucose Monitoring and Dextrose Addition

• When glucose falls to 250 mg/dL, add dextrose 5% to IV fluids while continuing insulin infusion 4
• This is critical: ketonemia takes longer to clear than hyperglycemia, so insulin must continue even after glucose normalizes 1, 4
• Target glucose between 150-200 mg/dL until DKA resolves 1, 4
• Never stop insulin infusion when glucose falls - this is the most common cause of persistent or worsening ketoacidosis 4

Monitoring Parameters

• Draw blood every 2-4 hours for: electrolytes, glucose, BUN, creatinine, osmolality, and venous pH 1, 4
• Venous pH is adequate for monitoring (typically 0.03 units lower than arterial pH) 4
• Measure β-hydroxybutyrate directly if available - this is superior to urine ketones, which only detect acetoacetate and acetone 1, 4

Resolution Criteria

DKA is resolved when ALL of the following are met: 1, 4

• Glucose <200 mg/dL
• Serum bicarbonate ≥18 mEq/L
• Venous pH >7.3
• Anion gap ≤12 mEq/L

Identifying and Treating Precipitating Causes

While initiating treatment, simultaneously evaluate for: 3

• Infection (most common precipitant) - obtain cultures, start empiric antibiotics if indicated
• Myocardial infarction - check troponin and ECG
• Stroke - perform neurological examination
• Medication non-adherence - obtain medication history
• New diagnosis of diabetes

Special Considerations

Euglycemic DKA

• If glucose is <250 mg/dL at presentation (euglycemic DKA, often SGLT-2 inhibitor-related), start dextrose-containing fluids immediately alongside insulin 1, 4
• Continue insulin at standard rate despite normal glucose - resolution depends on clearing ketones, not glucose 1

Mild/Moderate DKA in Stable Patients

• Subcutaneous rapid-acting insulin analogs combined with aggressive fluid management can be as effective as IV insulin 3, 1
• This approach may be safer and more cost-effective for uncomplicated cases in emergency departments or step-down units 3
• Requires adequate nurse training, frequent bedside glucose monitoring, and appropriate follow-up 3

Bicarbonate Use

• Bicarbonate is NOT recommended for DKA patients with pH >7.0 3, 1
• Multiple studies show no benefit in resolution of acidosis or time to discharge 3

Critical Pitfalls to Avoid

1. Stopping insulin when glucose normalizes - this causes recurrent ketoacidosis 1, 4
2. Inadequate potassium monitoring and replacement - insulin therapy causes rapid intracellular potassium shift 1
3. Failing to add dextrose at glucose 250 mg/dL - prevents continued insulin therapy needed for ketone clearance 1, 4
4. Premature transition to subcutaneous insulin - give basal insulin 2-4 hours before stopping IV insulin to prevent rebound 3
5. Over-rapid correction in children - increases cerebral edema risk 5

Transition to Subcutaneous Insulin

Once DKA is fully resolved: 1, 4

• Administer basal insulin (glargine, detemir, or degludec) 2-4 hours before stopping IV insulin 3
• When patient can eat, start basal-bolus regimen with short/rapid-acting insulin before meals 1, 4
• Continue IV insulin for 1-2 hours after first subcutaneous dose to ensure adequate plasma levels 4