Management of Diabetic Ketoacidosis (DKA) in a Ward Setting
For uncomplicated mild-to-moderate DKA in a ward setting, use aggressive fluid resuscitation with isotonic saline followed by subcutaneous rapid-acting insulin analogs combined with frequent monitoring, which is equally effective, safer, and more cost-effective than IV insulin. 1, 2, 3
Initial Assessment and Diagnosis
Confirm DKA diagnosis with the following laboratory criteria 3:
- Blood glucose >250 mg/dL
- Arterial pH <7.3
- Serum bicarbonate <15 mEq/L
- Presence of ketonemia or ketonuria
- Anion gap >12 mEq/L
Obtain comprehensive labs including plasma glucose, electrolytes with calculated anion gap, serum ketones (β-hydroxybutyrate preferred), blood urea nitrogen, creatinine, osmolality, arterial blood gases, complete blood count, urinalysis, and ECG 2, 3. If infection is suspected, obtain bacterial cultures from urine, blood, and throat 3.
Critical pitfall: Identify and treat precipitating factors immediately—infection, myocardial infarction, stroke, pancreatitis, insulin omission, or SGLT2 inhibitor use—as failure to address the underlying cause leads to treatment failure 2, 3.
Fluid Resuscitation
Begin 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 circulatory volume and tissue perfusion 1, 2, 3. This aggressive initial fluid replacement is critical as it improves insulin sensitivity and is essential for recovery 2.
After the first hour, continue fluid replacement based on hemodynamic 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 3. Aim to replace 50% of estimated fluid deficit in the first 8-12 hours 1.
Monitor fluid input/output and clinical examination continuously to assess progress 2.
Insulin Therapy for Ward-Appropriate DKA
For mild-to-moderate uncomplicated DKA in a ward setting, use subcutaneous rapid-acting insulin analogs (0.1 units/kg every 1 hour or 0.2 units/kg every 2 hours) combined with aggressive fluid management. 1, 2, 3 This approach is equally effective, safer, and more cost-effective than IV insulin 1, 2.
Critical requirement: Ensure adequate fluid replacement, frequent point-of-care blood glucose monitoring every 2-4 hours, and appropriate follow-up to avoid recurrent DKA 1, 2.
For moderate-to-severe DKA or mentally obtunded patients, continuous IV insulin at 0.1 units/kg/hour remains the standard of care and requires ICU-level monitoring 2, 3. If plasma glucose does not fall by 50 mg/dL in the first hour, check hydration status and double the insulin infusion rate every hour until achieving a steady decline of 50-75 mg/h 3.
Critical pitfall: Never stop insulin therapy when glucose falls below 250 mg/dL—instead add dextrose to IV fluids while continuing insulin until ketoacidosis resolves, as premature termination causes recurrent DKA 2, 3.
Electrolyte Management
Potassium Replacement (Most Critical)
If K+ <3.3 mEq/L, DO NOT start insulin therapy—aggressively replace potassium first to prevent life-threatening cardiac arrhythmias and respiratory muscle weakness. 3 Total body potassium depletion is universal in DKA despite potentially normal or elevated initial levels due to acidosis 2.
Once K+ ≥3.3 mEq/L and adequate urine output is confirmed, add 20-30 mEq potassium per liter of IV fluid (use 2/3 KCl and 1/3 KPO₄) 2, 3. Target serum potassium of 4-5 mEq/L throughout treatment 2, 3.
If K+ >5.5 mEq/L initially, withhold potassium but monitor closely every 2 hours, as levels will drop rapidly with insulin therapy 1, 2.
Critical pitfall: Inadequate potassium monitoring and replacement is a leading cause of mortality in DKA 3.
Bicarbonate
Do NOT administer bicarbonate for pH >6.9-7.0. 1, 2, 3 Studies consistently show bicarbonate makes no difference in resolution of acidosis or time to discharge and may worsen ketosis, cause hypokalemia, and increase cerebral edema risk 1, 2, 3.
Monitoring During Treatment
Draw blood every 2-4 hours to determine serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH 2, 3. Venous pH is typically 0.03 units lower than arterial pH and is adequate for monitoring 3.
Monitor blood glucose every 2-4 hours while the patient takes nothing by mouth 1, 2. Direct measurement of β-hydroxybutyrate in blood is the preferred method for monitoring DKA resolution 3.
Resolution Criteria
DKA is resolved when ALL of the following are met 2, 3:
- Glucose <200 mg/dL
- Serum bicarbonate ≥18 mEq/L
- Venous pH >7.3
- Anion gap ≤12 mEq/L
Target glucose between 150-200 mg/dL until these resolution parameters are achieved 3.
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. 2, 3 This overlap period is essential 2.
Recent evidence suggests adding low-dose basal insulin analog during IV insulin infusion can help prevent rebound hyperglycemia without increasing hypoglycemia risk 2.
When the patient can eat, start a multiple-dose schedule using a combination of short/rapid-acting and intermediate/long-acting insulin 3.
Discharge Planning
Provide structured discharge communication including medication changes, pending tests, and follow-up needs 2. Ensure patients have appropriate medications, supplies, and prescriptions at discharge to avoid dangerous gaps in care 2.
Education must include recognition, prevention, and management of DKA, diabetes self-management, blood glucose monitoring, home glucose goals, and when to call their provider 1, 2. Schedule follow-up appointments prior to discharge to increase attendance likelihood 2.
For patients on SGLT2 inhibitors, discontinue these medications 3-4 days before any planned surgery to prevent euglycemic DKA. 3
Common Pitfalls to Avoid
- Premature termination of insulin therapy before complete ketosis resolution leads to recurrent DKA 2, 3
- Inadequate fluid resuscitation delays recovery and worsens outcomes 2
- Failure to add dextrose when glucose falls below 250 mg/dL while continuing insulin 3
- Inadequate potassium monitoring and replacement causes cardiac arrhythmias 2, 3
- Not identifying or treating the underlying precipitating cause leads to treatment failure 2
- Overly rapid correction of osmolality increases cerebral edema risk 3