What is the initial management for Diabetic Ketoacidosis (DKA)?

Initial Management of Diabetic Ketoacidosis (DKA)

Begin with aggressive fluid resuscitation using isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour during the first hour to restore circulatory volume and tissue perfusion, followed by continuous intravenous insulin infusion at 0.1 units/kg/hour once potassium levels are adequate. 1, 2, 3

Immediate Assessment and Diagnosis

Before initiating treatment, confirm DKA diagnosis with the following criteria:

• Blood glucose >250 mg/dL 3
• Arterial pH <7.3 3
• Serum bicarbonate <15 mEq/L 3
• Presence of ketonemia or ketonuria (preferably measured as β-hydroxybutyrate, not nitroprusside method) 2, 3

Obtain initial laboratory evaluation including plasma glucose, electrolytes with calculated anion gap, blood urea nitrogen/creatinine, serum ketones, arterial blood gases, complete blood count, electrocardiogram, and urinalysis. 2, 3

Identify precipitating factors such as infection, myocardial infarction, stroke, insulin omission, pancreatitis, or SGLT2 inhibitor use. 3

Fluid Resuscitation Protocol

Start with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour (approximately 1-1.5 L in average adults) during the first hour. 1, 2, 3 This aggressive initial fluid replacement is critical for restoring tissue perfusion and improving insulin sensitivity. 3

After the first hour, continue fluid replacement based on hydration status, electrolyte levels, and urine output, aiming to correct estimated deficits within 24 hours. 3

When serum glucose reaches 250 mg/dL, switch to 5% dextrose with 0.45-0.75% NaCl to prevent hypoglycemia while continuing insulin therapy to clear ketosis. 2, 3 This is a critical step—never interrupt insulin infusion when glucose falls; instead, add dextrose. 2

Insulin Therapy

Do NOT start insulin if serum potassium is <3.3 mEq/L—aggressively replace potassium first to prevent life-threatening cardiac arrhythmias and respiratory muscle weakness. 3 This is a common pitfall that can lead to mortality. 3

Once potassium is ≥3.3 mEq/L, start continuous intravenous regular insulin infusion at 0.1 units/kg/hour without an initial bolus. 2, 3 For critically ill and mentally obtunded patients, continuous IV insulin is the standard of care. 3

Continue insulin infusion until complete resolution of ketoacidosis (pH >7.3, serum bicarbonate ≥18 mEq/L, and anion gap ≤12 mEq/L) regardless of glucose levels. 1, 2, 3 Premature termination of insulin therapy before ketosis resolution is a leading cause of treatment failure. 2, 4

If plasma glucose does not fall by 50 mg/dL in the first hour, check hydration status and double the insulin infusion rate hourly until achieving a steady decline of 50-75 mg/hour. 3

Alternative for Mild-to-Moderate Uncomplicated DKA

For mild-to-moderate uncomplicated DKA in non-critically ill patients, subcutaneous rapid-acting insulin analogs combined with aggressive fluid management may be equally effective, safer, and more cost-effective than IV insulin. 3 However, continuous IV insulin remains standard for severe DKA. 3

Electrolyte Management

Potassium Replacement

If potassium is 3.3-5.5 mEq/L, add 20-30 mEq/L potassium (2/3 KCl and 1/3 KPO₄) to IV fluids once adequate urine output is confirmed. 2, 3 Maintain serum potassium between 4-5 mEq/L throughout treatment. 2, 3

If potassium is >5.5 mEq/L, withhold potassium initially but monitor closely, as levels will drop rapidly with insulin therapy. 3

Total body potassium depletion is universal in DKA despite initial serum levels, and insulin therapy will further lower serum potassium. 3 Inadequate potassium monitoring and replacement is a leading cause of DKA mortality. 3

Bicarbonate Administration

Bicarbonate is NOT recommended for DKA patients with pH >6.9-7.0. 3 Studies show no difference in resolution of acidosis or time to discharge with bicarbonate use, and it may worsen ketosis, cause hypokalemia, and increase cerebral edema risk. 3, 5

Bicarbonate may be considered only if pH falls below 6.9, or when pH is <7.2 with bicarbonate <10 mEq/L in the peri-intubation period to prevent hemodynamic collapse. 5

Monitoring During Treatment

Draw blood every 2-4 hours to determine serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH. 1, 2, 3

Check blood glucose every 1-2 hours. 2

Follow venous pH (typically 0.03 units lower than arterial pH) and anion gap to monitor resolution of acidosis. 2, 3

Direct measurement of β-hydroxybutyrate in blood is preferred over nitroprusside method, which only detects acetoacetic acid and acetone, not the predominant ketone body. 2, 3

Resolution Criteria and Transition

DKA is resolved when ALL of the following are met:

• Glucose <200 mg/dL 3
• Serum bicarbonate ≥18 mEq/L 1, 2, 3
• Venous pH >7.3 1, 2, 3
• Anion gap ≤12 mEq/L 1, 2, 3

When transitioning to subcutaneous insulin, administer basal insulin (intermediate or long-acting) 2-4 hours BEFORE stopping IV insulin infusion to prevent recurrence of ketoacidosis and rebound hyperglycemia. 3 This overlap period is essential and failure to do so is a common cause of DKA recurrence. 3, 4

Once the patient can eat, transition to a multiple-dose insulin schedule using a combination of short/rapid-acting and intermediate/long-acting insulin. 1, 3

Additional Considerations

Thromboprophylaxis

DKA creates a hypercoagulable state that increases thrombosis risk. 1 Enoxaparin can be started upon admission after initial fluid resuscitation has begun as part of standard hospital thromboprophylaxis protocols. 1

Nutrition

Early initiation of oral nutrition has been shown to reduce ICU and overall hospital length of stay. 5 The American Diabetes Association does not recommend keeping DKA patients NPO as standard practice—allow patients to eat when able while providing appropriate insulin coverage. 1

Treatment of Precipitating Causes

Identify and treat underlying causes such as infection (obtain cultures and administer antibiotics if indicated), myocardial infarction, stroke, or discontinue precipitating medications. 3 SGLT2 inhibitors must be discontinued 3-4 days before any planned surgery to prevent euglycemic DKA. 3

Critical Pitfalls to Avoid

• Premature termination of insulin therapy before complete ketosis resolution 2, 4
• Starting insulin when potassium is <3.3 mEq/L 3
• Interrupting insulin infusion when glucose falls without adding dextrose 2
• Inadequate potassium monitoring and replacement 2, 3
• Overly rapid correction of osmolality, which increases cerebral edema risk 3, 5
• Stopping IV insulin without administering basal subcutaneous insulin 2-4 hours prior 3, 4
• Using bicarbonate in patients with pH >6.9-7.0 3, 5