What are the immediate management steps for Diabetic Ketoacidosis (DKA)?

Immediate Management of Diabetic Ketoacidosis (DKA)

Begin aggressive fluid resuscitation with isotonic saline (0.9% NaCl) 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 simultaneously monitoring and replacing potassium to prevent life-threatening hypokalemia. 1, 2

Initial Assessment and Laboratory Evaluation

Obtain the following immediately upon presentation:

• Plasma glucose, serum ketones, electrolytes with calculated anion gap, arterial blood gases (ABG), and venous pH 1, 2
• Blood urea nitrogen/creatinine, osmolality, complete blood count, electrocardiogram 1, 2
• Urinalysis and urine ketones 1, 2
• If infection suspected: bacterial cultures of blood, urine, and throat; chest X-ray if clinically indicated 1

Diagnostic criteria confirming DKA: plasma glucose >250 mg/dL, arterial pH <7.30, serum bicarbonate <18 mEq/L, and positive serum/urine ketones 2

Fluid Resuscitation Protocol

Hour 1: Administer isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour to restore intravascular volume and renal perfusion 1, 2, 3

Subsequent hours: Continue fluid replacement to correct estimated deficits within 24 hours, targeting total fluid replacement of approximately 1.5-2 times the 24-hour maintenance requirements 1, 2

A critical nuance: While isotonic saline remains the standard, recent research suggests balanced crystalloid solutions may achieve faster DKA resolution, though guidelines have not yet incorporated this change 4

Insulin Therapy

Start continuous IV regular insulin infusion at 0.1 units/kg/hour WITHOUT an initial bolus 2, 3

• Goal: reduce plasma glucose by 50-75 mg/dL per hour 2
• If glucose does not fall by 50 mg/dL in the first hour, double the insulin infusion rate hourly until steady decline achieved 2
• Critical: Continue insulin infusion until DKA resolves, regardless of glucose levels 3
• When glucose reaches 200 mg/dL, add dextrose to IV fluids while maintaining insulin infusion to clear ketones 2

The 2025 guidelines from the American Diabetes Association now recommend starting insulin without a bolus, which differs from older protocols that used 0.1 units/kg bolus 2. British guidelines suggest adding subcutaneous glargine alongside IV insulin for faster resolution, though this is not yet standard in U.S. practice 4.

Electrolyte Management: Potassium is Critical

Potassium replacement must begin early to prevent life-threatening hypokalemia:

• Once renal function is confirmed and serum potassium <5.3 mEq/L, add 20-30 mEq/L potassium to IV fluids 1, 2
• Monitor serum potassium closely every 2-4 hours, as insulin therapy drives potassium intracellularly 1, 2
• Common pitfall: Failure to replace potassium adequately is a leading cause of cardiac arrhythmias and death in DKA 2

Also monitor and replace phosphate and magnesium as needed, though these are less immediately critical 4

Monitoring During Treatment

Blood glucose: Check every 1-2 hours 2

Laboratory panel (electrolytes, glucose, BUN, creatinine, osmolality, venous pH): Draw every 2-4 hours 1, 2, 3

Follow venous pH and anion gap to monitor resolution of acidosis, targeting venous pH >7.3 and anion gap ≤12 mEq/L 2

Bicarbonate: Generally NOT Recommended

Do not administer bicarbonate routinely, as it provides no benefit in resolution of acidosis and increases risks of hypokalemia, worsening ketosis, and cerebral edema 5, 4

Exception: Consider IV bicarbonate only if pH <6.9 or when pH <7.2 with serum bicarbonate <10 mEq/L in the peri-intubation period to prevent hemodynamic collapse 4

Identifying and Treating Precipitating Causes

Simultaneously address underlying triggers:

• Infections (most common): administer appropriate antibiotics 1, 6
• Myocardial infarction, stroke, sepsis 5, 2
• Insulin omission or nonadherence 6
• SGLT2 inhibitors: Discontinue 3-4 days before surgery; monitor for euglycemic DKA (can occur with normal glucose) 2, 6

Transition to Subcutaneous Insulin: Timing is Everything

DKA resolution criteria (all must be met):

• Glucose <200 mg/dL
• Serum bicarbonate ≥18 mEq/L
• Venous pH >7.3
• Anion gap ≤12 mEq/L 2, 3

Critical transition protocol:

1. Administer basal insulin (glargine or detemir) 2-4 hours BEFORE stopping IV insulin 5, 1, 2
2. Once patient can eat, start multiple-dose insulin schedule combining rapid-acting and long-acting insulin 1, 3

Most common error leading to DKA recurrence: Stopping IV insulin without prior basal insulin administration 1. This creates an insulin-free interval that allows ketogenesis to restart.

Special Considerations for Critically Ill Patients

Airway management: If respiratory failure is impending, proceed directly to intubation and mechanical ventilation; do NOT use BiPAP due to aspiration risk 4

Nutrition: Allow oral intake when patient is able to eat; keeping patients NPO is not standard practice and may prolong hospital stay 3, 4

Thromboprophylaxis: DKA creates a hypercoagulable state; initiate enoxaparin per standard hospital protocols after initial fluid resuscitation 3

Comorbidities requiring modified approach: pregnancy, renal disease, congestive heart failure, acute coronary syndrome, and older age all necessitate adjusted fluid rates and closer monitoring 7

Prevention of Cerebral Edema

Though rare, cerebral edema is the most feared complication, particularly in younger patients:

• Avoid overly rapid correction of hyperglycemia 4, 8
• Avoid excessive hypotonic fluids 8
• If signs of cerebral edema develop (headache, altered mental status, bradycardia), immediately administer mannitol or hypertonic saline 8