What are the latest guidelines for managing Diabetic Ketoacidosis (DKA)?

Management of Diabetic Ketoacidosis (DKA)

Diagnostic Criteria

DKA is diagnosed when blood glucose >250 mg/dL, arterial pH <7.3, serum bicarbonate <15 mEq/L, and ketonemia or ketonuria are present. 1

• Obtain plasma glucose, blood urea nitrogen, creatinine, serum ketones, electrolytes with calculated anion gap, osmolality, urinalysis, arterial blood gases, complete blood count with differential, and electrocardiogram 1, 2
• Direct measurement of β-hydroxybutyrate in blood is the preferred monitoring method, as nitroprusside only detects acetoacetic acid and acetone 1, 2
• Obtain bacterial cultures (urine, blood, throat) if infection is suspected and administer appropriate antibiotics 1, 2
• Identify precipitating factors: infection (most common), myocardial infarction, stroke, pancreatitis, trauma, insulin omission, or SGLT2 inhibitor use 1, 2

Initial Fluid Resuscitation

Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour (approximately 1-1.5 L) during the first hour. 1

• Subsequent fluid choice depends on hydration status, serum electrolyte levels, and urine output 1
• When serum glucose reaches 250 mg/dL, switch to 5% dextrose with 0.45-0.75% NaCl to prevent hypoglycemia while continuing insulin therapy 1
• Aim to correct estimated fluid deficits within 24 hours 1
• Avoid changing serum osmolality by more than 3 mOsm/kg/h to reduce cerebral edema risk 2

Insulin Therapy

Start continuous intravenous regular insulin infusion at 0.1 units/kg/hour for moderate to severe DKA. 1, 2

• If plasma glucose does not fall by 50 mg/dL in the first hour, check hydration status; if adequate, double the insulin infusion rate hourly until achieving a steady decline of 50-75 mg/h 1, 2
• Continue insulin infusion until complete resolution of ketoacidosis (pH >7.3, bicarbonate ≥18 mEq/L, anion gap ≤12 mEq/L) regardless of glucose levels 1
• Target glucose between 150-200 mg/dL until DKA resolution parameters are met 1
• For mild-to-moderate uncomplicated DKA, subcutaneous rapid-acting insulin analogs combined with aggressive fluid management are equally effective, safer, and more cost-effective than IV insulin 1, 2

Critical Pitfall to Avoid

• Premature termination of insulin therapy before complete resolution of ketosis is a common cause of DKA recurrence 1
• Interruption of insulin infusion when glucose falls below 250 mg/dL without adding dextrose causes persistent or worsening ketoacidosis 1

Potassium Management

If serum K+ <3.3 mEq/L, delay insulin therapy and aggressively replace potassium first to prevent life-threatening arrhythmias and respiratory muscle weakness. 1

• Once K+ ≥3.3 mEq/L and adequate urine output is confirmed, add 20-30 mEq/L potassium (2/3 KCl and 1/3 KPO₄) to IV fluids 1, 2
• Target serum potassium of 4-5 mEq/L throughout treatment 1
• If K+ >5.5 mEq/L initially, withhold potassium but monitor closely, as levels will drop rapidly with insulin therapy 1, 2
• Total body potassium depletion is universal in DKA despite potentially normal or elevated initial levels due to acidosis 1, 2

Bicarbonate Therapy

Bicarbonate is NOT recommended for DKA patients with pH >6.9-7.0. 1, 2

• Studies show no difference in resolution of acidosis or time to discharge with bicarbonate use 1, 2
• Bicarbonate may worsen ketosis, cause hypokalemia, and increase cerebral edema risk 1
• For pH <6.9, consider 100 mmol sodium bicarbonate in 400 mL sterile water at 200 mL/h 2
• For pH 6.9-7.0, consider 50 mmol sodium bicarbonate in 200 mL sterile water at 200 mL/h 2

Monitoring During Treatment

Draw blood every 2-4 hours to determine serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH. 1, 2

• Venous pH (typically 0.03 units lower than arterial pH) and anion gap can be followed to monitor resolution of acidosis 1, 2
• Monitor fluid input/output, hemodynamic parameters, and clinical examination 2
• Continuous cardiac monitoring is crucial in severe DKA to detect arrhythmias early 2

Resolution Criteria

DKA is resolved when glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L. 1, 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. 1, 2

• Once the patient can eat, start a multiple-dose schedule using a combination of short/rapid-acting and intermediate/long-acting insulin 1, 2
• If the patient remains NPO after DKA resolution, continue IV insulin and fluid replacement, supplementing with subcutaneous regular insulin as needed 1
• Adding low-dose basal insulin analog during IV insulin infusion can help prevent rebound hyperglycemia 1, 2

Special Considerations

SGLT2 inhibitors must be discontinued 3-4 days before any planned surgery to prevent euglycemic DKA. 1, 2

• Hyperglycemia has been de-emphasized in recent guidelines due to increasing incidence of euglycemic DKA 3
• Higher blood urea nitrogen at presentation is a risk factor for cerebral edema 2, 4
• Cerebral edema occurs in 0.7-1.0% of children with DKA and is responsible for most DKA-related deaths in children 2, 4

Discharge Planning

• Identify outpatient diabetes care providers 1
• Ensure understanding of diabetes diagnosis, glucose monitoring, home glucose goals, and when to call healthcare professionals 1
• Provide education on recognition, prevention, and management of DKA to reduce recurrence and readmission 2
• Ensure clear communication about medication changes, follow-up needs, and sick-day management 5