What is the treatment for diabetic ketoacidosis?

Treatment of Diabetic Ketoacidosis

Begin immediate fluid resuscitation with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hr in the first hour, followed by continuous IV regular insulin at 0.1 units/kg/hr once potassium is >3.3 mEq/L, while aggressively monitoring and replacing electrolytes until acidosis resolves. 1

Initial Diagnostic Confirmation

Before initiating treatment, confirm DKA diagnosis with the following criteria 1:

• Blood glucose >250 mg/dL (though euglycemic DKA can occur, especially with SGLT2 inhibitors) 2
• Arterial pH <7.3 1
• Bicarbonate <15 mEq/L 1
• Moderate ketonemia or ketonuria 1

Measure β-hydroxybutyrate in blood directly rather than urine ketones, as the nitroprusside method only detects acetoacetic acid and acetone, missing β-hydroxybutyrate which is the predominant acid in DKA 1. This is a critical distinction that affects monitoring accuracy.

Fluid Resuscitation Protocol

First Hour

• Administer isotonic saline (0.9% NaCl) at 15-20 mL/kg/hr (approximately 1-1.5 L) 1, 3
• This aggressive initial resuscitation restores circulatory volume and tissue perfusion 1

Subsequent Hours

• Continue fluid replacement at 4-14 mL/kg/hr based on hemodynamic status 1
• Monitor hydration status frequently to guide ongoing management 1
• Avoid excessive fluid administration in patients with cardiac dysfunction or pleural effusions 3

Insulin Therapy

Initiation

• Do not start insulin until potassium is >3.3 mEq/L to avoid life-threatening hypokalemia 1
• Begin continuous IV regular insulin at 0.1 units/kg/hr after fluid resuscitation has started 1, 4
• In patients with cardiac compromise, omit the initial bolus 3

Titration

• If glucose does not fall by 50-75 mg/dL in the first hour, double the insulin infusion rate 1
• Target gradual glucose reduction of 50-75 mg/dL/hour 3
• When blood glucose reaches 200-250 mg/dL, add dextrose (D5W or D10W) to IV fluids while continuing insulin infusion 1, 3
• Continue insulin until DKA resolves: pH >7.3, bicarbonate ≥18 mEq/L, and anion gap normalized 1

Critical pitfall: Do not discontinue insulin prematurely, as ketosis may persist even after glucose normalization 3. This is a common error leading to DKA recurrence.

Electrolyte Management

Potassium Replacement

• Monitor serum potassium every 2-4 hours 1
• Begin replacement when levels fall below 5.2-5.5 mEq/L, provided adequate urine output 1, 3
• Typical replacement is 20-30 mEq per liter of IV fluid 1
• Severe hypokalemia increases risk of poor outcomes approximately 4-fold 5

Phosphate

• Monitor levels and consider replacement if <1.0 mg/dL, especially with cardiac dysfunction, anemia, or respiratory depression 1

Bicarbonate

• Generally not recommended unless pH <6.9 1, 6
• Vigorous bicarbonate therapy is indicated only in severe metabolic acidosis where rapid increase in plasma CO2 is crucial 6

Monitoring Requirements

Frequent Assessments

• Check blood glucose every 1-2 hours until stable 1, 3
• Draw electrolytes, BUN, creatinine, and venous pH every 2-4 hours 1, 3
• Monitor for cerebral edema signs (headache, altered mental status, seizures, bradycardia), particularly in children and young adults 1, 3

Osmolality Monitoring

• Ensure osmolality change does not exceed 3-8 mOsm/kg/hour to prevent cerebral edema 3, 7

Transition to Subcutaneous Insulin

Once DKA resolves (glucose <200 mg/dL, bicarbonate ≥18 mEq/L, pH >7.3) 1, 3:

1. Administer subcutaneous basal insulin 2-4 hours before discontinuing IV insulin 1, 3
2. Continue IV insulin for 1-2 hours after starting subcutaneous insulin to ensure adequate plasma levels 1
3. This overlap prevents recurrence of ketoacidosis 1

Treatment of Precipitating Factors

Identify and treat underlying causes 1:

• Infection (most common precipitant) 7, 5
• Medication non-adherence (particularly insulin) 5
• Trauma or surgery 1
• New-onset diabetes 1

Non-adherence to insulin treatment accounts for 40.4% of DKA cases 5, making patient education critical for prevention.

Special Populations

Youth with Type 2 Diabetes

• In patients presenting with ketosis/ketoacidosis, initiate subcutaneous or IV insulin to rapidly correct hyperglycemia and metabolic derangement 8
• Once acidosis resolves, initiate metformin while continuing subcutaneous insulin 8
• Initial therapy should address hyperglycemia regardless of ultimate diabetes type, as presentation often overlaps 8

Patients with Cardiac Dysfunction

• Avoid insulin bolus 3
• Position upright if hemodynamically stable to improve ventilation 3
• Consider thoracentesis for significant pleural effusions contributing to respiratory compromise 3

Critical Complications to Prevent

• Hypoglycemia during treatment: Prevent by adding dextrose when glucose <200-250 mg/dL 1, 5
• Hypokalemia: The only independent predictor of in-hospital mortality in one study 5
• Cerebral edema: More common in children; treat immediately if suspected 1
• DKA recurrence: Prevent with proper insulin transition overlap 1

Discharge Planning

• Schedule follow-up appointment before discharge 1
• Ensure clear communication with outpatient providers about medication changes 1
• Educate patients on sick-day management and when to seek care 2

In-hospital mortality from DKA can reach 12% 5, but this is largely preventable through proper potassium supplementation and avoidance of hypoglycemia from insulin therapy.