What is the treatment for Diabetic Ketoacidosis (DKA)?

Treatment of Diabetic Ketoacidosis (DKA)

Begin immediate treatment with aggressive isotonic saline resuscitation at 15-20 mL/kg/hour for the first hour, followed by continuous intravenous insulin infusion at 0.1 units/kg/hour (with a 0.1-0.15 units/kg bolus in adults), while closely monitoring and replacing potassium to maintain levels between 4-5 mEq/L. 1, 2, 3

Initial Assessment and Laboratory Evaluation

Obtain the following tests immediately upon presentation:

• Plasma glucose, arterial blood gases, serum ketones (β-hydroxybutyrate preferred), electrolytes with calculated anion gap, osmolality, blood urea nitrogen, creatinine 4, 1, 2
• Complete blood count with differential, urinalysis with urine ketones, electrocardiogram 4, 1
• Bacterial cultures (blood, urine, throat) if infection is suspected 1, 2
• Chest X-ray only if clinically indicated 1

The diagnostic criteria require: blood glucose >250 mg/dL, arterial pH <7.3, serum bicarbonate <15 mEq/L, and presence of ketonemia or ketonuria 2. However, be aware that euglycemic DKA (particularly with SGLT2 inhibitor use) is increasingly recognized, so hyperglycemia should not be overemphasized 5, 2.

Fluid Resuscitation Protocol

First Hour

• Administer isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour (approximately 1-1.5 L in average adults) 1, 2, 3
• This aggressive initial fluid replacement restores tissue perfusion and improves insulin sensitivity 3

Subsequent Fluid Management

• Fluid choice depends on hydration status, corrected serum sodium, and urine output 4, 2
• When serum glucose reaches 250 mg/dL, switch to 5% dextrose with 0.45-0.75% NaCl to prevent hypoglycemia while continuing insulin therapy until ketoacidosis resolves 2, 3
• Total fluid replacement should correct estimated deficits within 24 hours 4, 2
• The change in serum osmolality should not exceed 3 mOsm/kg/hour to minimize cerebral edema risk 4

Pediatric Fluid Considerations (≤20 years)

• Initial fluid is isotonic saline at 10-20 mL/kg/hour for the first hour 4
• Initial reexpansion should not exceed 50 mL/kg over the first 4 hours 4
• Continue at 1.5 times the 24-hour maintenance requirements to achieve smooth rehydration over 48 hours 4

Insulin Therapy

Adult Protocol

• First, confirm serum potassium is ≥3.3 mEq/L before starting insulin 2. If K+ <3.3 mEq/L, delay insulin and aggressively replace potassium first to prevent life-threatening arrhythmias 2
• Administer IV bolus of regular insulin at 0.1-0.15 units/kg body weight 4, 3
• Follow immediately with continuous IV infusion at 0.1 units/kg/hour (typically 5-7 units/hour in adults) 4, 1, 3
• Target glucose decline of 50-75 mg/dL per hour 4, 2

Pediatric Protocol

• Do NOT give an initial insulin bolus in children 3
• Start directly with continuous infusion at 0.1 units/kg/hour 3

Insulin Dose Adjustment

• If glucose does not fall by 50 mg/dL in the first hour, verify adequate hydration, then double the insulin infusion rate every hour until achieving steady decline 4, 2, 3
• When glucose reaches 250 mg/dL, reduce insulin to 0.05-0.1 units/kg/hour and add dextrose to IV fluids 4, 1
• Continue insulin infusion until complete resolution of ketoacidosis, regardless of glucose levels 2, 3. This is critical—premature termination is a common error 2

Alternative for Mild-Moderate Uncomplicated DKA

• Subcutaneous rapid-acting insulin analogs combined with aggressive fluid management are equally effective and potentially safer than IV insulin 2, 3
• However, continuous IV insulin remains standard for critically ill and mentally obtunded patients 2, 3

Potassium Management

This is critical—inadequate potassium monitoring and replacement is a leading cause of mortality in DKA 2

Potassium Replacement Algorithm

• If K+ <3.3 mEq/L: HOLD insulin therapy and aggressively replace potassium until ≥3.3 mEq/L 2
• If K+ 3.3-5.5 mEq/L: Add 20-30 mEq/L potassium to IV fluids (use 2/3 KCl and 1/3 KPO₄) once adequate urine output confirmed 4, 1, 2, 3
• If K+ >5.5 mEq/L: Withhold potassium initially but monitor closely, as levels will drop rapidly with insulin therapy 2
• Target serum potassium of 4-5 mEq/L throughout treatment 2, 3

Rationale: Despite sometimes presenting with normal or elevated potassium, total body potassium depletion is universal in DKA, and insulin therapy drives potassium intracellularly, causing potentially fatal hypokalemia 2.

Bicarbonate Therapy

Bicarbonate is NOT recommended for DKA patients with pH >6.9-7.0 2, 3. Studies show no benefit in resolution time or outcomes, and bicarbonate may worsen ketosis, cause hypokalemia, and increase cerebral edema risk 2.

Monitoring During Treatment

• Draw blood every 2-4 hours for serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH 1, 2, 3
• Follow venous pH (typically 0.03 units lower than arterial pH) and anion gap to monitor acidosis resolution 2
• Direct measurement of β-hydroxybutyrate in blood is the preferred monitoring method, as nitroprusside only measures acetoacetic acid and acetone 2, 3
• Check blood glucose every 2-4 hours while patient is NPO 1

Resolution Criteria

DKA is resolved when ALL of the following are met:

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

Important caveat: Ketonemia typically takes longer to clear than hyperglycemia, so insulin therapy must continue until all criteria are met 4, 3.

Transition to Subcutaneous Insulin

This is the most common error leading to DKA recurrence:

• Administer basal insulin (glargine, detemir, or NPH) 2-4 hours BEFORE stopping IV insulin infusion 1, 2, 3
• Never stop IV insulin without prior basal insulin administration—this overlap period is essential to prevent recurrence of ketoacidosis and rebound hyperglycemia 1, 2, 3
• Once patient can eat, start a multiple-dose schedule using combination of short/rapid-acting and intermediate/long-acting insulin 1, 2

Treatment of Precipitating Causes

Identifying and treating the underlying cause is crucial for successful DKA management 2, 3:

• Infection (most common)—obtain cultures and administer appropriate antibiotics 1, 2
• Myocardial infarction, stroke, pancreatitis, trauma 4, 2
• Insulin omission or inadequacy 4, 2
• SGLT2 inhibitors—must be discontinued 3-4 days before any planned surgery 2

Common Pitfalls to Avoid

• Premature termination of insulin before complete ketosis resolution 2
• Stopping IV insulin without prior basal insulin administration 1, 2
• Failure to add dextrose when glucose falls below 250 mg/dL 2
• Inadequate potassium monitoring and replacement 2
• Overly rapid correction of osmolality (>3 mOsm/kg/hour), increasing cerebral edema risk 4, 2
• Starting insulin when K+ <3.3 mEq/L 2

Discharge Planning

• Identify outpatient diabetes care providers before discharge 2
• Ensure medication reconciliation with cross-checking of home and hospital medications 3
• Schedule follow-up appointments prior to discharge 3
• Provide education on insulin administration, glucose monitoring, and sick day management 1, 3
• Transmit discharge summaries to primary care clinician as soon as possible 3