What is the immediate management for severe diabetic ketoacidosis (DKA)?

Immediate Management of Severe Diabetic Ketoacidosis

Begin aggressive fluid resuscitation with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour during the first hour, followed immediately by continuous intravenous regular insulin infusion at 0.1 units/kg/hour, while closely monitoring and replacing potassium to prevent life-threatening hypokalemia. 1, 2, 3

Initial Resuscitation and Stabilization

Fluid Therapy - First Priority

• Start with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour for the first hour to restore intravascular volume and renal perfusion 1, 2, 3
• Continue fluid replacement to correct estimated deficits within 24 hours, targeting 1.5-2 times the 24-hour maintenance requirements 1, 2
• After initial volume expansion, subsequent fluid choice depends on hydration status and electrolyte levels 2, 3
• When serum glucose reaches 250 mg/dL, add 5% dextrose to IV fluids (with 0.45-0.75% NaCl) while continuing insulin to clear ketosis 2, 3

Insulin Therapy - Second Priority

• For adults with severe DKA, administer an IV bolus of regular insulin at 0.15 units/kg body weight ONLY after confirming serum potassium ≥3.3 mEq/L 3
• Immediately follow with continuous IV regular insulin infusion at 0.1 units/kg/hour (typically 5-7 units/hour in adults) 1, 2, 3
• Target a glucose decline of 50-75 mg/dL per hour 1, 2
• If glucose does not fall by 50 mg/dL in the first hour, double the insulin infusion rate hourly until steady decline is achieved 1, 2
• Continue insulin therapy until complete resolution of ketoacidosis (pH >7.3, bicarbonate ≥18 mEq/L, anion gap ≤12 mEq/L), regardless of glucose levels 2, 3

Critical caveat: Never give insulin bolus if potassium is <3.3 mEq/L, as this can cause fatal cardiac arrhythmias 3

Electrolyte Management - Concurrent Priority

Potassium Replacement

• Monitor potassium levels every 2-4 hours as insulin therapy drives potassium intracellularly and can cause life-threatening hypokalemia 1, 2, 3
• Once renal function is confirmed and serum potassium is <5.3 mEq/L, add 20-30 mEq/L potassium to IV fluids (2/3 KCl and 1/3 KPO₄) 1, 2, 3
• Maintain serum potassium between 4-5 mmol/L throughout treatment 2, 3
• If potassium is <3.3 mEq/L, hold insulin and give potassium replacement first 3

Laboratory Monitoring Protocol

Initial Assessment

• Obtain plasma glucose, blood urea nitrogen/creatinine, serum ketones, electrolytes with calculated anion gap, osmolality, urinalysis, urine ketones, arterial blood gases, complete blood count, and electrocardiogram 1, 2

Ongoing Monitoring

• Check blood glucose every 1-2 hours 1, 2
• Draw blood every 2-4 hours for serum electrolytes, glucose, BUN, creatinine, osmolality, and venous pH 1, 2, 3
• Follow venous pH (typically 0.03 units lower than arterial pH) and anion gap to monitor resolution of acidosis 1, 2, 3
• Direct measurement of β-hydroxybutyrate in blood is preferred over nitroprusside method, which misses the primary ketone body 2, 3

Critical Pitfalls to Avoid

• Never stop insulin infusion when glucose normalizes - ketoacidosis takes longer to resolve than hyperglycemia; continue insulin until pH >7.3, bicarbonate ≥18 mEq/L, and anion gap ≤12 mEq/L 2, 3
• Never give insulin without checking potassium first - insulin-induced hypokalemia can cause cardiac arrest 1, 2, 3
• Never stop IV insulin without giving basal subcutaneous insulin 2-4 hours prior - this prevents rebound ketoacidosis 1, 2, 3
• Avoid bicarbonate administration unless pH <6.9, as it can worsen ketosis, cause hypokalemia, and increase cerebral edema risk 2, 4
• Avoid rapid overcorrection of hyperglycemia, which can precipitate cerebral edema, particularly in younger patients 4

Identification of Precipitating Causes

• Obtain bacterial cultures (urine, blood, throat) if infection is suspected and administer appropriate antibiotics 2
• Identify and treat underlying precipitating events such as sepsis, myocardial infarction, stroke, medication non-adherence, or new diabetes diagnosis 3, 5
• Consider SGLT2 inhibitor use as a cause of euglycemic DKA (DKA with normal or mildly elevated glucose) 1

Resolution Criteria and Transition

DKA is resolved when ALL of the following are met: glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L 1, 2, 3

When these criteria are met, administer basal subcutaneous insulin 2-4 hours before stopping IV insulin to prevent recurrence 1, 2, 3