Diabetic Ketoacidosis Treatment Protocol
Begin aggressive fluid resuscitation with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour immediately, followed by intravenous insulin therapy once potassium levels are confirmed adequate, and continue both until complete resolution of ketoacidosis (pH >7.3, bicarbonate ≥18 mEq/L, anion gap ≤12 mEq/L, and glucose <200 mg/dL). 1, 2, 3
Initial Assessment and Diagnosis
Confirm DKA diagnosis with the following criteria: 2
- Blood glucose >250 mg/dL
- Venous pH <7.3
- Serum bicarbonate <15 mEq/L
- Moderate ketonuria or ketonemia
Obtain immediate laboratory evaluation: 2
- Complete metabolic panel
- Venous blood gases (venous pH is typically 0.03 units lower than arterial pH)
- Complete blood count
- Urinalysis
- Serum ketones (β-hydroxybutyrate preferred over nitroprusside method)
- Calculate anion gap: [Na⁺] - ([Cl⁻] + [HCO₃⁻])
Classify severity: 2
- Mild DKA: pH 7.25-7.30, bicarbonate 15-18 mEq/L, alert mental status
- Moderate DKA: pH 7.00-7.24, bicarbonate 10-15 mEq/L, drowsy mental status
- Severe DKA: pH <7.00, bicarbonate <10 mEq/L, requires intensive monitoring
Identify precipitating factors such as infection, myocardial infarction, or stroke, and obtain bacterial cultures if infection is suspected. 1, 2
Fluid Resuscitation Protocol
Start with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour to restore circulatory volume and tissue perfusion. 1, 2
Adjust subsequent fluid choice based on hydration state, serum electrolytes, and urine output. 2
Add dextrose 5% (D5) to IV fluids when serum glucose falls to 250 mg/dL while continuing insulin infusion to clear ketones—this is critical to prevent hypoglycemia while resolving ketoacidosis. 3
Target glucose between 150-200 mg/dL until DKA resolution criteria are met. 3
Plan total fluid replacement to correct estimated deficits within 24 hours, monitoring carefully for fluid overload in patients with renal or cardiac compromise. 2
Insulin Therapy
For moderate to severe DKA, administer intravenous regular insulin infusion as the preferred route. 4, 5
For mild DKA in stable patients, subcutaneous rapid-acting insulin analogs combined with aggressive fluid management can be as effective as IV insulin. 1
Continue insulin therapy until complete resolution of ketoacidosis (pH >7.3, bicarbonate ≥18 mEq/L, anion gap ≤12 mEq/L), not just until glucose normalizes. 1, 3
Never discontinue insulin when glucose falls below 200-250 mg/dL—this is a common cause of persistent or worsening ketoacidosis. Instead, add dextrose to IV fluids and continue insulin. 1, 3
Electrolyte Management
Potassium replacement is critical: 1, 2
- Once renal function is assured, add 20-30 mEq/L potassium to IV fluids
- Maintain serum potassium between 4-5 mmol/L
- Monitor closely as insulin administration drives potassium intracellularly, causing hypokalemia
Bicarbonate therapy is NOT recommended except potentially when pH <6.9, and even then evidence is limited. 1, 5
Phosphate replacement is not routinely indicated unless levels fall to <0.32 mmol/L or patient has cardiac dysfunction, anemia, or respiratory depression. 5
Monitoring During Treatment
Draw blood every 2-4 hours to measure: 1, 3
- Serum electrolytes
- Glucose
- Blood urea nitrogen
- Creatinine
- Osmolality
- Venous pH
Follow venous pH and anion gap to monitor resolution of acidosis. 2, 3
Use β-hydroxybutyrate measurement (not nitroprusside method) for accurate ketone monitoring, as ketonemia typically takes longer to clear than hyperglycemia. 1, 3
Resolution Criteria
DKA is resolved when ALL of the following are met: 3
- Glucose <200 mg/dL
- Serum bicarbonate ≥18 mEq/L
- Venous pH >7.3
- Anion gap ≤12 mEq/L
Transition to Subcutaneous Insulin
Administer basal subcutaneous insulin 2-4 hours BEFORE stopping IV insulin to prevent rebound hyperglycemia and recurrence of ketoacidosis. 1, 3
Continue IV insulin infusion for 1-2 hours after starting subcutaneous insulin to ensure adequate plasma insulin levels. 3
Start a multiple-dose schedule using combination of short/rapid-acting and intermediate/long-acting insulin when patient can eat. 1, 3
Critical Pitfalls to Avoid
Premature termination of insulin therapy before complete resolution of ketosis leads to DKA recurrence. 1, 6
Interrupting insulin infusion when glucose falls is the most common cause of persistent or worsening ketoacidosis—always add dextrose instead. 1, 3
Inadequate fluid resuscitation worsens DKA outcomes. 1
Insufficient timing or dosing of subcutaneous insulin before discontinuing IV insulin causes rebound hyperglycemia. 6
Inadequate potassium monitoring and replacement can lead to life-threatening hypokalemia. 1, 2
Failing to identify and treat the precipitating cause leads to DKA recurrence. 1, 2
Special Considerations
For euglycemic DKA (glucose <250 mg/dL with ketoacidosis), start D5 alongside 0.9% NaCl at the beginning of insulin treatment. 3
Severe DKA (pH <7.00) requires intensive monitoring, potentially including central venous and intra-arterial pressure monitoring. 2
Patient education on recognition, prevention, and management of DKA is essential before discharge to prevent recurrence. 2