From the Guidelines
Management of diabetic ketoacidosis (DKA) in the ICU should prioritize continuous intravenous insulin as the standard of care for critically ill and mentally obtunded individuals, with a focus on restoring circulatory volume, resolving ketoacidosis, and correcting electrolyte imbalances, as recommended by the most recent guidelines 1. The initial management of DKA in the ICU involves:
- Intravenous fluid resuscitation with normal saline at 15-20 mL/kg/hr for the first hour, then 250-500 mL/hr depending on hydration status and cardiovascular stability
- Insulin therapy initiated with an IV insulin bolus of 0.1 units/kg followed by a continuous infusion at 0.1 units/kg/hr
- Potassium replacement to maintain serum levels between 4-5 mEq/L, starting when potassium is below 5.3 mEq/L
- Hourly monitoring of blood glucose, with a target reduction of 50-75 mg/dL per hour
- Addition of dextrose to IV fluids when glucose reaches 200-250 mg/dL, while continuing insulin to clear ketones Key considerations in DKA management include:
- Identifying and treating the underlying cause of DKA, such as infection or medication non-compliance
- Frequent monitoring of electrolytes, vital signs, and mental status
- Transitioning to subcutaneous insulin only after resolution of ketoacidosis, with overlap between IV and subcutaneous insulin for 1-2 hours to prevent rebound hyperglycemia, as supported by recent studies 1
- Avoiding the use of bicarbonate unless there is severe acidosis (pH < 6.9) or significant cardiovascular complications, as its use has been shown to have no significant difference in outcomes 1
From the Research
DKA Management in ICU
- DKA is an acute life-threatening emergency in patients with diabetes, requiring reversing metabolic derangements, correcting volume depletion, electrolyte imbalances, and acidosis while concurrently treating the precipitating illness 2.
- Management of DKA in the ICU involves aggressive treatment, including intravenous fluids, insulin therapy, and electrolyte replacement, as well as identification and treatment of the underlying precipitating event 3, 4.
- The use of isotonic normal saline for initial volume replacement is a traditional approach, but recent studies suggest that large volumes of normal saline may lead to undesirable outcomes such as hyperchloremic metabolic acidosis 5.
- Balanced crystalloids, such as lactated Ringers, may be a better choice for initial resuscitation in DKA patients, as they may reduce the risk of complications related to hyperchloremia and improve clinical outcomes 5.
Treatment Approaches
- Insulin therapy is titrated against the change in blood glucose concentration, and potassium is administered as required 6.
- Bicarbonate is employed in extreme acidosis, but its administration may contribute to the development of hypokalemia, CSF acidosis, and tissue hypoxia 6.
- Discharge plans should include appropriate choice and dosing of insulin regimens and interventions to prevent recurrence of DKA, as well as patient education programs focusing on adherence to insulin and self-care guidelines during illness 4.
Special Considerations
- 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 in DKA management 2.
- Guidelines often lack sufficient recommendations regarding specific conditions and comorbidities, and institutions may develop their own protocols for internal use or do not routinely use any protocols, resulting in inconsistencies in treatment and increased risk of complications and suboptimal outcomes 2.