Treatment of Diabetic Ketoacidosis
For critically ill patients with DKA, initiate continuous intravenous insulin infusion combined with aggressive fluid resuscitation, electrolyte replacement, and identification of the precipitating cause, while mild uncomplicated cases can be managed with subcutaneous rapid-acting insulin analogs in emergency or step-down units. 1, 2
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, 3.
Identify and treat precipitating factors such as infection, myocardial infarction, stroke, or medication non-adherence, as these must be addressed simultaneously with metabolic correction 1, 2, 4.
Fluid Resuscitation
Begin aggressive fluid replacement with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour during the first hour to restore circulatory volume and tissue perfusion 1, 2, 3. This initial rapid fluid administration is critical for hemodynamic stabilization 5.
Continue fluid replacement with monitoring of input/output, hemodynamic parameters, and clinical examination to guide ongoing hydration needs 2, 3.
Insulin Therapy
For Severe/Complicated DKA:
Administer intravenous regular insulin with a bolus of 0.15 U/kg body weight, followed by continuous infusion at 0.1 U/kg/hour 2, 6. This remains the standard of care for critically ill and mentally obtunded patients 1.
For Mild/Uncomplicated DKA:
Subcutaneous rapid-acting insulin analogs combined with aggressive fluid management can be equally effective and more cost-effective than IV insulin for stable patients in emergency departments or step-down units 1, 3. This approach requires adequate nurse training, frequent bedside glucose monitoring, and appropriate follow-up 1.
Critical Insulin Management Points:
Do not discontinue insulin when glucose falls below 200-250 mg/dL - this is a common pitfall that leads to persistent or worsening ketoacidosis 2, 3, 4. Instead, add dextrose to the hydrating solution while continuing insulin infusion 2, 3.
Target blood glucose levels of 100-180 mg/dL during treatment 2, 3.
Electrolyte Management
Monitor potassium levels closely as total body potassium deficits are common despite potentially normal or elevated initial serum levels due to acidosis 2, 3, 5.
Add 20-40 mEq/L potassium to the infusion when serum levels fall below 5.5 mEq/L, once renal function is assured 1, 2, 3.
Bicarbonate administration is generally not recommended as multiple studies show no difference in resolution of acidosis or time to discharge 1, 3.
Monitoring During Treatment
Draw blood every 2-4 hours for determination of serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH 1, 3.
Follow venous pH (typically 0.03 units lower than arterial pH) and anion gap to monitor resolution of acidosis 3.
Resolution Criteria
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 2, 3.
Note that ketonemia typically takes longer to clear than hyperglycemia 3.
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 failure to overlap appropriately is a common cause of DKA recurrence 4.
Recent evidence suggests that administering a low dose of basal insulin analog in addition to IV insulin infusion during treatment may prevent rebound hyperglycemia without increased hypoglycemia risk 1.
Special Populations
Youth with Type 2 Diabetes:
Patients presenting with ketosis/ketoacidosis require immediate treatment with subcutaneous or intravenous insulin and fluid replacement under supervision of an experienced physician 1. Once acidosis resolves, initiate metformin while continuing subcutaneous insulin 1.
For youth with marked hyperglycemia (≥250 mg/dL) without acidosis, treat initially with long-acting insulin while metformin is initiated and titrated 1.
Patients on SGLT2 Inhibitors:
Recognize euglycemic DKA in patients prescribed sodium-glucose cotransporter 2 inhibitors, as this presents a diagnostic challenge 5, 7. These medications must be discontinued 3-4 days before any planned surgery to prevent DKA 2.
Common Pitfalls to Avoid
Premature termination of insulin therapy before complete resolution of ketosis leads to DKA recurrence 2, 3, 4.
Inadequate fluid resuscitation worsens metabolic derangements 2, 3.
Interruption of insulin infusion when glucose levels fall is a frequent cause of persistent ketoacidosis - always add dextrose instead 3.
Insufficient timing or dosing of subcutaneous insulin before discontinuing IV insulin causes rebound hyperglycemia and ketosis 4.
Discharge Planning
Develop a structured discharge plan including medication reconciliation, ensuring prescriptions are filled and reviewed, and scheduling follow-up appointments before discharge to reduce readmission rates 1, 2, 3.
Provide education on recognition and prevention of DKA, insulin adjustment during illness, glucose and ketone monitoring, and importance of medication adherence 1, 8.
Ensure clear communication with outpatient providers through prompt transmission of discharge summaries 1.