What are the guidelines for Diabetic Ketoacidosis (DKA) management?

From the Guidelines

Diabetic ketoacidosis (DKA) management requires prompt intervention with intravenous fluids, insulin therapy, and electrolyte replacement, with the goal of restoring circulatory volume, resolving ketoacidosis, and correcting electrolyte imbalances, as recommended by the most recent guidelines 1.

Key Components of DKA Management

• Begin with IV fluid resuscitation using normal saline at 15-20 mL/kg/hr for the first hour, then reduce to 250-500 mL/hr based on hemodynamic status.
• Start IV regular insulin as a continuous infusion at 0.1 units/kg/hr after initial fluid resuscitation, avoiding insulin boluses, as this approach has been shown to be effective in managing DKA 1.
• Monitor blood glucose hourly, aiming for a decrease of 50-75 mg/dL per hour, and adjust insulin infusion accordingly.
• When glucose reaches 200-250 mg/dL, add dextrose to IV fluids (D5 or D10) while continuing insulin to clear ketones.
• Replace potassium when levels are below 5.2 mEq/L and urine output is adequate, targeting 4-5 mEq/L, to prevent hypokalemia and cardiac complications.
• Monitor electrolytes, particularly potassium, phosphate, and magnesium, every 2-4 hours initially, and adjust replacement therapy as needed.
• Check venous pH and bicarbonate to track acidosis resolution, and continue treatment until anion gap normalizes, bicarbonate is >15 mEq/L, and pH is >7.3.
• Investigate and treat the underlying trigger of DKA, commonly infection, medication non-adherence, or new-onset diabetes, to prevent recurrence.
• Transition to subcutaneous insulin only when the patient is eating and metabolically stable, with overlap between IV and subcutaneous insulin to prevent rebound hyperglycemia, as recommended by recent studies 1.

Important Considerations

• The use of bicarbonate in patients with DKA has been shown to make no difference in resolution of acidosis or time to discharge, and its use is generally not recommended 1.
• Patients with uncomplicated DKA may be treated with subcutaneous insulin in the emergency department or step-down units, an approach that may be safer and more cost-effective than treatment with intravenous insulin 1.
• Successful transition from intravenous to subcutaneous insulin requires administration of basal insulin 2-4 hours prior to the intravenous insulin being stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia 1.

From the Research

DKA Guidelines

• The management of Diabetic Ketoacidosis (DKA) requires hospitalization for aggressive intravenous fluids, insulin therapy, electrolyte replacement, and identification and treatment of the underlying precipitating event, along with frequent monitoring of the patient's clinical and laboratory states 2.
• Effective treatment of DKA can be achieved using low-dose intravenous insulin and 2 to 3 liters of isotonic saline at 500 ml/hr to replace extracellular fluids, followed by 2 to 4 L of 5% glucose in 0.45% saline with potassium chloride and/or potassium phosphate to replace intracellular fluids at 250 ml/hr 3.
• The most common precipitating causes for DKA include infections, new diagnosis of diabetes, and nonadherence to insulin therapy, and clinicians should be aware of the occurrence of DKA in patients prescribed sodium-glucose co-transporter 2 inhibitors 2.

Treatment Approach

• Insulin therapy is titrated against the change in blood glucose concentration, and isotonic saline is the initial replacement fluid, with potassium administered as required 4.
• Bicarbonate is employed in extreme acidosis, but its administration may contribute to the development of hypokalemia, CSF acidosis, and tissue hypoxia 4.
• Large-volume resuscitation with isotonic normal saline (NS) may lead to undesirable outcomes such as hyperchloremic metabolic acidosis, and balanced crystalloids, such as lactated Ringers, may be a better choice for initial resuscitation in DKA patients 5.

Patient Management

• Discharge plans should include appropriate choice and dosing of insulin regimens and interventions to prevent recurrence of DKA, and patient education programs focusing on adherence to insulin and self-care guidelines during illness can help reduce future episodes of DKA 2.
• Special patient factors and comorbidities, such as pregnancy, renal disease, congestive heart failure, acute coronary syndrome, older age, and use of sodium-glucose cotransporter-2 (SGLT2) inhibitors, should receive more careful attention and consideration, and guidelines often lack sufficient recommendations regarding specific conditions and comorbidities 6.