What is the treatment for diabetes ketoacidosis (DKA) with severe hyperglycemia and metabolic acidosis?

Diabetic Ketoacidosis: Laboratory Findings and Treatment

Laboratory Findings for Diagnosis

DKA is diagnosed by the triad: hyperglycemia (typically >250 mg/dL, though euglycemic DKA can occur), metabolic acidosis (pH <7.3, bicarbonate <18 mEq/L, anion gap >10 mEq/L), and elevated ketones in blood or urine. 1, 2

Essential Initial Laboratory Tests

• Draw plasma glucose, blood urea nitrogen, creatinine, serum ketones (β-hydroxybutyrate preferred), electrolytes with calculated anion gap, serum osmolality, urinalysis, arterial blood gases, complete blood count with differential, and electrocardiogram 2, 3
• Direct measurement of β-hydroxybutyrate in blood is superior to nitroprusside methods, which only detect acetoacetic acid and acetone 2
• Obtain bacterial cultures (urine, blood, throat) if infection is suspected as a precipitating cause 3

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Treatment Protocol

1. Fluid Resuscitation (First Priority)

Begin with balanced electrolyte solutions (preferred over 0.9% saline) at 15-20 mL/kg/h during the first hour to restore circulatory volume and tissue perfusion. 2, 3, 4

• Continue fluid replacement to correct estimated deficits within 24 hours 2
• Critical pitfall: Do not allow serum osmolality to change by more than 3 mOsm/kg/h to prevent cerebral edema 2, 4
• Monitor fluid input/output and hemodynamic parameters continuously 2

2. Insulin Therapy

For critically ill and mentally obtunded patients, continuous intravenous insulin is the standard of care. 1

IV Insulin Protocol:

• Administer IV bolus of regular insulin at 0.1-0.15 U/kg body weight 2, 3
• Follow with continuous infusion at 0.1 U/kg/h 2, 3
• If plasma glucose does not fall by 50 mg/dL in the first hour, double the insulin infusion hourly until achieving a steady decline of 50-75 mg/dL/h 2
• When glucose reaches 200-250 mg/dL, add dextrose to IV fluids while continuing insulin to clear ketones 4

Alternative for Uncomplicated DKA:

• Subcutaneous rapid-acting insulin analogs combined with aggressive fluid management show no significant difference in outcomes for mild-moderate DKA 1
• This approach may be safer and more cost-effective than IV insulin in emergency departments or step-down units 1

3. Electrolyte Management

Potassium Replacement (Critical):

• Total body potassium is depleted despite potentially normal or elevated initial levels due to acidosis 2
• Once renal function is confirmed and serum potassium <5.5 mEq/L, add 20-40 mEq/L potassium to infusion fluids 2, 3
• Target maintenance of serum potassium 4-5 mEq/L 2
• If initial potassium <3.3 mEq/L, delay insulin therapy until potassium is restored to prevent arrhythmias, cardiac arrest, and respiratory muscle weakness 2

Bicarbonate Therapy:

• Bicarbonate use is generally NOT recommended, as studies show no difference in resolution of acidosis or time to discharge 1, 2
• Consider only if pH <6.9: give 100 mmol sodium bicarbonate in 400 mL sterile water at 200 mL/h 2
• For pH 6.9-7.0: give 50 mmol sodium bicarbonate in 200 mL sterile water at 200 mL/h 2

Phosphate Replacement:

• Routine phosphate replacement shows no beneficial effects on clinical outcomes 2
• Consider only if cardiac dysfunction, anemia, respiratory depression, or serum phosphate <1.0 mg/dL present 2

4. Monitoring Requirements

• Check blood glucose every 1-2 hours initially, then every 2-4 hours once stable 2, 4
• Draw serum electrolytes, glucose, BUN, creatinine, osmolality, and venous pH every 2-4 hours 2, 3
• Continuous cardiac monitoring is crucial to detect arrhythmias early, especially given electrolyte shifts 2

5. Resolution Criteria

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

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

6. Transition to Subcutaneous Insulin

Administer basal insulin (glargine or detemir) 2-4 hours BEFORE stopping IV insulin to prevent recurrence of ketoacidosis and rebound hyperglycemia. 1, 2, 3

• This is the most common error leading to DKA recurrence—never stop IV insulin without prior basal insulin administration 3
• For newly diagnosed patients, initiate multidose regimen at approximately 0.5-1.0 U/kg/day using combination of short/rapid-acting and intermediate/long-acting insulin 2

7. Identify and Treat Precipitating Causes

• Most common triggers: infections, new diabetes diagnosis, insulin nonadherence 5
• SGLT2 inhibitors should be discontinued 3-4 days before surgery to prevent DKA 1, 2
• Treat sepsis, myocardial infarction, or stroke if identified 1

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Critical Pitfalls to Avoid

• Never stop IV insulin without administering basal insulin 2-4 hours prior 3
• Avoid rapid correction of hyperglycemia and osmolality (>3 mOsm/kg/h) to prevent cerebral edema 2, 4
• Do not delay insulin if potassium <3.3 mEq/L—correct potassium first 2
• Avoid excessive fluid administration in patients with cardiac dysfunction or pleural effusions 4
• Do not discontinue insulin prematurely—ketosis may persist after glucose normalization 4

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Discharge Planning

• Structured discharge plan should include diabetes education, medication reconciliation, and scheduled follow-up within 1-2 weeks 1, 3
• Educate on recognition, prevention, and management of DKA to prevent recurrence 2
• Ensure uninterrupted access to insulin and glucose monitoring supplies 1