What are the immediate management steps for Diabetic Ketoacidosis (DKA)?

Immediate Management of Diabetic Ketoacidosis (DKA)

Begin aggressive fluid resuscitation with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour during the first hour, followed by continuous intravenous regular insulin at 0.1 units/kg/hour once potassium is ≥3.3 mEq/L, while closely monitoring and replacing electrolytes, particularly potassium. 1, 2

Initial Assessment and Diagnosis

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

• Plasma glucose >250 mg/dL 1, 2
• Arterial pH <7.30 (or venous pH <7.3) 1, 2
• Serum bicarbonate <18 mEq/L 1
• Positive serum and urine ketones 1

Obtain comprehensive laboratory evaluation including plasma glucose, electrolytes with calculated anion gap, serum ketones, blood urea nitrogen/creatinine, osmolality, arterial blood gases, complete blood count, urinalysis with urine ketones, and electrocardiogram. 1, 2

Identify and begin treating precipitating causes immediately (infection, myocardial infarction, stroke, insulin omission, pancreatitis, or medications like SGLT2 inhibitors). 2, 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 to restore intravascular volume and renal perfusion. 1, 2

After initial resuscitation:

• Continue fluid replacement to correct estimated deficits within 24 hours, aiming for 1.5-2 times the 24-hour maintenance requirements 1
• Subsequent fluid choice depends on hydration status, serum electrolyte levels, and urine output 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 2

Insulin Therapy

Critical: 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. 2

Once potassium ≥3.3 mEq/L:

• Start continuous intravenous regular insulin infusion at 0.1 units/kg/hour without an initial bolus 1, 2
• Goal: reduce plasma glucose by 50-75 mg/dL per hour 1
• If glucose does not fall by 50 mg/dL in the first hour, check hydration status; if adequate, double the insulin infusion rate hourly until steady glucose decline is achieved 1, 2

Continue insulin infusion until complete resolution of ketoacidosis, regardless of glucose levels - this is critical to prevent recurrence. 4, 2

Electrolyte Management

Potassium Replacement (Most Critical)

Potassium monitoring and replacement is essential - total body potassium depletion is universal in DKA, and insulin therapy will further lower serum levels. 2

• If K+ <3.3 mEq/L: Delay insulin therapy and aggressively replace potassium until ≥3.3 mEq/L 2
• If K+ 3.3-5.3 mEq/L: Add 20-30 mEq/L potassium to IV fluids (use 2/3 KCl and 1/3 KPO₄) once adequate urine output is confirmed 1, 2
• If K+ >5.3 mEq/L: Withhold potassium initially but monitor closely, as levels will drop rapidly with insulin therapy 2
• Target serum potassium: 4-5 mEq/L throughout treatment 2

Bicarbonate

Bicarbonate administration is NOT recommended for pH >6.9-7.0 - studies show no benefit in resolution time or outcomes, and it may worsen ketosis, cause hypokalemia, and increase cerebral edema risk. 2, 5

Bicarbonate may be considered only if pH <6.9 or in 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

Check blood glucose every 1-2 hours. 1

Follow venous pH and anion gap to monitor resolution of acidosis, with goals of venous pH >7.3 and anion gap ≤12 mEq/L. 1, 2

Monitor vital signs and neurologic status continuously to detect complications, particularly cerebral edema. 2, 6

Resolution Criteria and Transition

DKA is resolved when ALL of the following are met:

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

Target glucose between 150-200 mg/dL until DKA resolution parameters are met. 2

Transition 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 - this overlap period is essential. 4, 2

Once the patient can eat, transition to a multiple-dose insulin schedule using combination of short/rapid-acting and intermediate/long-acting insulin. 4, 2

Critical Pitfalls to Avoid

• Never stop insulin infusion prematurely when glucose falls - add dextrose to IV fluids and continue insulin until ketoacidosis resolves 2
• Never start insulin with potassium <3.3 mEq/L - this can cause fatal arrhythmias 2
• Never interrupt IV insulin without prior subcutaneous basal insulin - this causes recurrence of DKA 4, 2
• Inadequate potassium monitoring and replacement is a leading cause of mortality in DKA 2
• Overly rapid correction of osmolality increases cerebral edema risk, particularly in children 2, 6

Special Considerations

SGLT2 inhibitors must be discontinued 3-4 days before any planned surgery to prevent euglycemic DKA (DKA with normal or mildly elevated glucose). 1, 3

For mild-to-moderate uncomplicated DKA in alert patients, subcutaneous rapid-acting insulin analogs combined with aggressive fluid management may be equally effective and safer than IV insulin, though continuous IV insulin remains standard for critically ill or obtunded patients. 2, 5

Thromboprophylaxis with enoxaparin should be initiated after initial fluid resuscitation as DKA creates a hypercoagulable state. 4