From the Guidelines
The treatment for acute Diabetic Ketoacidosis (DKA) involves the administration of intravenous insulin and aggressive fluid management to restore circulatory volume and tissue perfusion, with the goal of resolving ketoacidosis and correcting electrolyte imbalance and acidosis.
Key Components of DKA Treatment
- Intravenous insulin: Continuous intravenous insulin is the standard of care for critically ill and mentally obtunded patients with DKA, as it allows for rapid and precise control of blood glucose levels 1.
- Aggressive fluid management: Providing adequate fluid replacement is crucial to restore circulatory volume and tissue perfusion, and to prevent dehydration and electrolyte imbalances 1.
- Basal insulin administration: Administering basal insulin 2-4 hours before stopping intravenous insulin can help prevent recurrence of ketoacidosis and rebound hyperglycemia 1.
- Subcutaneous insulin: Patients with uncomplicated DKA may be treated with subcutaneous rapid-acting insulin analogs in the emergency department or step-down units, which may be safer and more cost-effective than intravenous insulin 1.
Important Considerations
- Individualization of treatment: Treatment should be individualized based on a careful clinical and laboratory assessment, taking into account the severity of DKA, the presence of underlying conditions, and the patient's overall health status 1.
- Treatment of underlying causes: It is essential to treat any correctable underlying cause of DKA, such as sepsis, myocardial infarction, or stroke 1.
- Avoidance of bicarbonate: The use of bicarbonate in patients with DKA is generally not recommended, as it has been shown to make no difference in the resolution of acidosis or time to discharge 1.
From the Research
Treatment Overview
The treatment for acute Diabetic Ketoacidosis (DKA) involves several key components, including:
- Aggressive administration of intravenous fluids with appropriate replacement of electrolytes, primarily potassium 2
- Administration of insulin, usually via an intravenous insulin infusion, which is continued until resolution of ketonemia 2, 3
- Treatment of the precipitating cause of DKA 4
- Close monitoring by experienced physicians to adjust therapy and identify complications 2, 4
Fluid and Electrolyte Replacement
- Replacement of the substantial fluid deficit with several liters of a physiological crystalloid solution is the first and most important step in treating DKA and hyperglycemic hyperosmolar state (HHS) 3
- Serum potassium concentrations need to be carefully monitored to guide its substitution 3
- The rate, amount, and type of fluid bolus can vary, with some protocols using 0.5 to 2 L of normal saline or Ringer's lactate over 15 minutes to 2 hours 5
Insulin Therapy
- Regular insulin or rapid-acting insulin analogues can be initially administered as an intravenous bolus followed by continuous infusion 3
- Insulin should be switched to subcutaneous injections only after correction of the acidosis and stable glucose concentrations within an acceptable range 3
- The intravenous insulin infusion rate is similar across different protocols, but there can be variability in the use of an insulin bolus 5
Monitoring and Prevention
- Electrolytes, phosphate, blood urea nitrogen, creatinine, urinalysis, complete blood cell count with differential, A1C, and electrocardiography should be evaluated for all patients diagnosed with DKA to identify causes and complications 4
- Prevention strategies include identifying diabetes before DKA develops, educating patients to manage high-risk situations, and ensuring uninterrupted access to therapies for diabetes 4