What is the treatment for diabetic ketoacidosis?

Treatment of Diabetic Ketoacidosis

In critically ill patients with DKA, continuous intravenous insulin with aggressive fluid resuscitation is the standard of care, while patients with mild, uncomplicated DKA may be treated with subcutaneous rapid-acting insulin analogs in the emergency department or step-down units. 1

Initial Assessment and Stabilization

Perform immediate laboratory evaluation including plasma glucose, blood urea nitrogen, creatinine, serum ketones (preferably β-hydroxybutyrate), electrolytes with calculated anion gap, arterial blood gases, and complete blood count to confirm diagnosis and assess severity. 1, 2

Identify and treat any precipitating factors such as infection, myocardial infarction, or stroke, as these must be addressed simultaneously with the metabolic derangement. 1, 2

Fluid Resuscitation

Begin aggressive fluid management with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour during the first hour to restore circulatory volume and tissue perfusion. 2, 3 This initial rapid fluid replacement is critical for correcting the severe dehydration that characterizes DKA. 1

Continue fluid replacement throughout treatment, monitoring input/output, hemodynamic parameters, and clinical examination to assess progress. 2

Insulin Therapy

For Severe/Critically Ill Patients:

• Administer intravenous regular insulin as a bolus of 0.15 U/kg body weight, followed by continuous infusion at 0.1 U/kg/hour. 2
• Continue insulin infusion until complete resolution of ketoacidosis, not just until glucose normalizes. 1, 3

For Mild/Uncomplicated DKA:

• Subcutaneous rapid-acting insulin analogs combined with aggressive fluid management can be as effective as intravenous insulin and may be safer and more cost-effective. 1, 3
• This approach requires adequate nurse training, frequent bedside glucose testing, and appropriate follow-up. 1

Glucose Management During Treatment

When blood glucose falls below 200-250 mg/dL, add dextrose to the hydrating solution while continuing insulin infusion. 2, 3 This is a critical step that prevents premature termination of insulin therapy, which is a common pitfall leading to persistent or recurrent ketoacidosis. 3, 4

Target blood glucose levels of 100-180 mg/dL during treatment. 2

Electrolyte Management

Potassium Replacement:

• Monitor potassium levels closely, as total body potassium deficits are common despite potentially normal or elevated initial serum levels due to acidosis. 2
• Once renal function is assured and serum potassium is known, add 20-40 mEq/L potassium to the infusion when serum levels fall below 5.5 mEq/L. 2
• Maintain serum potassium between 4-5 mmol/L throughout treatment. 3

Bicarbonate:

Bicarbonate administration is generally not recommended for DKA patients, as multiple studies have shown no difference in resolution of acidosis or time to discharge. 1, 3 This represents a shift from older practices and should be avoided in routine management.

Monitoring During Treatment

Draw blood every 2-4 hours for determination of serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH (typically 0.03 units lower than arterial pH). 2, 3

Follow venous pH and anion gap to monitor resolution of acidosis, as ketonemia typically takes longer to clear than hyperglycemia. 3

Resolution Criteria

DKA is considered resolved when ALL of the following criteria are met: 2, 3

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

Do not discontinue insulin therapy based on glucose levels alone, as this leads to recurrent ketoacidosis. 3, 4

Transition to Subcutaneous Insulin

Administer basal insulin 2-4 hours before stopping the intravenous insulin to prevent recurrence of ketoacidosis and rebound hyperglycemia. 1, 2, 3 This timing is critical and represents one of the most common errors in DKA management. 4

Recent evidence suggests that administering a low dose of basal insulin analog in addition to intravenous insulin infusion during treatment may prevent rebound hyperglycemia without increased risk of hypoglycemia. 1

Start a multiple-dose schedule using a combination of short/rapid-acting and intermediate/long-acting insulin when the patient is able to eat. 3

Common Pitfalls to Avoid

• Premature termination of insulin therapy before complete resolution of ketosis is the most common cause of recurrent DKA. 3, 4
• Inadequate fluid resuscitation can worsen the metabolic derangement. 2, 3
• Stopping insulin infusion when glucose falls below 200-250 mg/dL without adding dextrose leads to persistent ketoacidosis. 3
• Insufficient timing or dosing of subcutaneous insulin before discontinuing intravenous insulin causes rebound hyperglycemia and ketosis. 4
• Failure to identify and treat the underlying precipitating cause leads to treatment failure and recurrence. 2

Discharge Planning

Develop a structured discharge plan including medication reconciliation, ensuring no chronic medications were stopped and new prescriptions are filled and reviewed. 1

Schedule follow-up appointments prior to discharge, as this increases the likelihood that patients will attend. 1

Provide education on recognition and prevention of DKA, including how to adjust insulin during illness, how to monitor glucose and ketone levels, and the importance of medication compliance. 5