What is the treatment for Diabetic Ketoacidosis (DKA)?

Treatment of Diabetic Ketoacidosis (DKA)

Begin immediate treatment with isotonic saline at 15-20 ml/kg/hour for the first hour, followed by continuous intravenous regular insulin at 0.1 units/kg/hour without an initial bolus, while closely monitoring and replacing potassium to maintain levels between 4-5 mEq/L. 1, 2, 3

Initial Assessment and Laboratory Evaluation

Obtain the following tests immediately upon presentation 4, 2, 3:

• Plasma glucose, arterial blood gases, serum ketones (preferably β-hydroxybutyrate), electrolytes with calculated anion gap, and osmolality 4, 2
• Complete blood count with differential, urinalysis with urine ketones, blood urea nitrogen, creatinine, and electrocardiogram 4
• Bacterial cultures (blood, urine, throat) if infection is suspected, as infection is one of the most common precipitating causes 4, 2, 5
• Chest X-ray only if clinically indicated—not routinely 6

Diagnostic criteria for DKA: Blood glucose >250 mg/dL, arterial pH <7.3, serum bicarbonate <15-18 mEq/L, and positive serum/urine ketones 4, 2. However, be aware that euglycemic DKA (normal or near-normal glucose) is increasingly recognized, particularly in patients on SGLT-2 inhibitors 7, 5.

Fluid Resuscitation

First Hour

Administer isotonic saline (0.9% NaCl) at 15-20 ml/kg body weight/hour (approximately 1-1.5 liters in average adults) to restore intravascular volume and renal perfusion 4, 2, 3. This aggressive initial fluid replacement is critical for hemodynamic stabilization 4.

Subsequent Fluid Management

After the first hour, adjust fluid choice based on corrected serum sodium (add 1.6 mEq to measured sodium for each 100 mg/dL glucose above 100 mg/dL) 4:

• If corrected sodium is low: Continue 0.9% NaCl at 4-14 ml/kg/hour 4
• If corrected sodium is normal or elevated: Switch to 0.45% NaCl at 4-14 ml/kg/hour 4
• Total fluid replacement should approximate 1.5 times the 24-hour maintenance requirements 1, 3

When plasma glucose reaches 250 mg/dL, add 5-10% dextrose to intravenous fluids while continuing insulin therapy 4, 2, 3. This prevents hypoglycemia while allowing continued insulin administration to clear ketosis—a critical step that is frequently missed 2, 3.

Recent evidence suggests balanced crystalloids like Sterofundin may be superior to normal saline, showing faster DKA resolution (13.8 vs 18.1 hours) and reduced fluid requirements, though this requires further validation 8.

Insulin Therapy

Start continuous intravenous regular insulin infusion at 0.1 units/kg/hour WITHOUT an initial bolus 1, 3. The American Diabetes Association guidelines have moved away from routine bolus dosing 1, 3.

Insulin Adjustment Protocol

• Target glucose decline of 50-75 mg/dL per hour 4, 2
• 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 steady glucose decline 4, 3
• When glucose reaches 250 mg/dL, decrease insulin to 0.05-0.1 units/kg/hour and add dextrose to IV fluids 4, 2
• Continue insulin infusion until complete resolution of ketoacidosis, NOT just until glucose normalizes 2, 3

Critical Pitfall

Never stop insulin infusion when glucose falls below 250 mg/dL—this is the most common error leading to persistent or worsening ketoacidosis 2, 3. Instead, add dextrose and reduce insulin rate while continuing therapy until acidosis resolves 4, 2.

Electrolyte Management

Potassium Replacement

Potassium monitoring and replacement is essential, 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 (use 2/3 KCl and 1/3 KPO₄) 4, 2, 3
• Maintain serum potassium between 4-5 mEq/L throughout treatment 2, 3
• If initial potassium is <3.3 mEq/L, delay insulin therapy and aggressively replace potassium first 4

Bicarbonate Administration

Bicarbonate is NOT recommended for DKA patients with pH >6.9-7.0 2, 3. Studies show no benefit in resolution of acidosis or time to discharge with bicarbonate use 2.

Phosphate

While total body phosphate is depleted in DKA, routine phosphate replacement beyond what is provided in the potassium formulation (1/3 as KPO₄) is not necessary 4.

Monitoring During Treatment

Check blood glucose every 1-2 hours 3. Draw venous blood every 2-4 hours to measure 2, 3:

• Electrolytes (sodium, potassium, chloride, bicarbonate)
• Glucose
• Blood urea nitrogen and creatinine
• Venous pH (typically 0.03 units lower than arterial pH—adequate for monitoring) 2, 3
• Calculate anion gap to track resolution 2

Direct measurement of β-hydroxybutyrate in blood is preferred over nitroprusside methods, as nitroprusside only detects acetoacetate and acetone, not the predominant ketone body β-hydroxybutyrate 2, 3.

Resolution Criteria

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

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

Transition to Subcutaneous Insulin

Once DKA is resolved and the patient can eat 1, 2, 3:

• Administer basal insulin (glargine or detemir) 2-4 hours BEFORE stopping the IV insulin infusion 1, 2, 3
• Start a multiple-dose insulin schedule combining rapid/short-acting with intermediate/long-acting insulin 1, 3

This 2-4 hour overlap is the most critical step to prevent recurrence of ketoacidosis and rebound hyperglycemia—stopping IV insulin without prior basal insulin administration is the most common error leading to DKA recurrence 1, 2.

Common Pitfalls to Avoid

• Premature termination of insulin before complete ketosis resolution leads to DKA recurrence 2, 3
• Stopping insulin when glucose normalizes without adding dextrose causes persistent ketoacidosis 2, 3
• Inadequate potassium monitoring and replacement can cause dangerous hypokalemia 2, 3
• Stopping IV insulin without prior basal insulin administration causes rebound hyperglycemia and ketoacidosis 1, 2
• Overly aggressive fluid administration in pediatric patients increases risk of cerebral edema 4
• Relying on urine ketones or nitroprusside methods is misleading as they don't measure β-hydroxybutyrate 2, 3

Special Considerations

Most DKA patients can be managed on general medical floors rather than intensive care units, with appropriate monitoring protocols 6. Patients typically can be discharged in 3-4 days with proper treatment 6, 8.