What is the treatment for severe ketoacidosis?

Treatment of Severe Ketoacidosis

For severe diabetic ketoacidosis (DKA) with pH <7.00, continuous intravenous insulin is the standard of care, combined with aggressive fluid resuscitation starting with isotonic saline at 15-20 mL/kg/hour for the first hour. 1

Initial Fluid Resuscitation

• Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour (approximately 1-1.5 liters in average adult) during the first hour to restore intravascular volume and renal perfusion 2, 1, 3
• After initial resuscitation, continue with 0.45% NaCl at 4-14 mL/kg/hour if corrected serum sodium is normal or elevated; use 0.9% NaCl if corrected serum sodium is low 1
• When glucose falls to 200-250 mg/dL, switch to 5% dextrose with 0.45-0.75% saline while continuing insulin infusion to prevent hypoglycemia and ensure complete ketoacidosis resolution 2, 1, 3

Insulin Therapy Protocol

• Start continuous IV regular insulin at 0.1 units/kg/hour for moderate to severe DKA 3
• If glucose does not fall by 50 mg/dL in the first hour, verify adequate hydration, then double the insulin infusion rate hourly until achieving steady decline of 50-75 mg/hour 3
• Continue insulin infusion until complete DKA resolution (pH >7.3, bicarbonate ≥18 mEq/L, anion gap ≤12 mEq/L, glucose <200 mg/dL) regardless of glucose levels 1, 3
• Target glucose of 150-200 mg/dL until resolution parameters are met 3

Critical Electrolyte Management

Potassium Replacement

• If K+ <3.3 mEq/L, delay insulin therapy and aggressively replace potassium first to prevent life-threatening arrhythmias and respiratory muscle weakness 3
• Once K+ ≥3.3 mEq/L and adequate urine output confirmed, add 20-30 mEq/L potassium to IV fluids (use 2/3 KCl and 1/3 KPO₄) 1, 3
• Maintain serum potassium between 4-5 mEq/L throughout treatment 1, 3
• Monitor closely as total body potassium is universally depleted despite potentially normal initial levels, and insulin therapy will further lower serum potassium 3

Bicarbonate Therapy

• Bicarbonate is NOT recommended for pH >6.9-7.0, as multiple studies show no difference in resolution of acidosis or time to discharge 2, 1, 3
• Bicarbonate may worsen ketosis, cause hypokalemia, and increase cerebral edema risk 3

Monitoring Requirements

• Monitor blood glucose every 1-2 hours until stable 1
• Draw blood every 2-4 hours to measure serum electrolytes, glucose, BUN, creatinine, osmolality, and venous pH 1, 3
• Follow venous pH (typically 0.03 units lower than arterial pH) and anion gap to monitor acidosis resolution 3
• Direct measurement of β-hydroxybutyrate in blood is preferred over nitroprusside method 3

Transition to Subcutaneous Insulin

• Administer basal insulin (intermediate or long-acting) 2-4 hours BEFORE stopping IV insulin to prevent recurrence of ketoacidosis and rebound hyperglycemia 2, 1, 3
• Recent evidence shows adding low-dose basal insulin analog during IV insulin infusion may prevent rebound hyperglycemia without increasing hypoglycemia risk 2
• Once patient can eat, start multiple-dose schedule combining short/rapid-acting with intermediate/long-acting insulin 3

Treatment of Underlying Precipitating Factors

• Identify and treat correctable causes such as sepsis, myocardial infarction, stroke, pancreatitis, or infection 2, 3
• Obtain bacterial cultures (urine, blood, throat) if infection suspected and administer appropriate antibiotics 3
• Consider insulin omission, SGLT2 inhibitor use (must be discontinued 3-4 days before surgery), or other medications as triggers 3

Critical Pitfalls to Avoid

• Premature termination of insulin before complete ketoacidosis resolution leads to DKA recurrence 3
• Stopping IV insulin when glucose falls without adding dextrose causes persistent or worsening ketoacidosis 3
• Inadequate potassium monitoring and replacement is a leading cause of mortality in DKA 3
• Overly rapid correction of osmolality increases cerebral edema risk, particularly in children 3
• Starting insulin therapy with K+ <3.3 mEq/L without correction first 3

Alternative Approach for Mild-Moderate Uncomplicated DKA

• Subcutaneous rapid-acting insulin analogs combined with aggressive fluid management are equally effective, safer, and more cost-effective than IV insulin for uncomplicated mild-moderate DKA 2, 3
• This approach requires adequate fluid replacement, frequent point-of-care glucose monitoring, treatment of concurrent infections, and appropriate follow-up 2
• However, continuous IV insulin remains standard for critically ill and mentally obtunded patients 2, 3