What are the treatment guidelines for diabetic ketoacidosis (DKA) based on the Joint British Diabetes Societies (JBDS) guidelines?

Treatment Guidelines for Diabetic Ketoacidosis Based on JBDS

The JBDS guidelines are not explicitly detailed in the provided evidence; however, British guidelines recommend using subcutaneous insulin glargine alongside continuous IV regular insulin, which achieves faster DKA resolution and shorter hospital stays compared to IV insulin alone. 1

Initial Assessment and Laboratory Evaluation

Obtain comprehensive laboratory workup immediately upon presentation:

• Plasma glucose, blood urea nitrogen/creatinine, serum ketones (β-hydroxybutyrate preferred), electrolytes with calculated anion gap, osmolality 2, 3
• Arterial blood gases, complete blood count with differential, electrocardiogram 2, 3
• Urinalysis and urine ketones 2
• Calculate corrected serum sodium: for each 100 mg/dL glucose above 100 mg/dL, add 1.6 mEq to sodium value 3
• Direct measurement of β-hydroxybutyrate in blood is preferred over nitroprusside method, which only measures acetoacetic acid and acetone 4

Diagnostic criteria require blood glucose >250 mg/dL (though euglycemic DKA is increasingly recognized), arterial pH <7.3, bicarbonate <15 mEq/L, and moderate ketonuria or ketonemia. 3, 5

If infection is suspected, obtain bacterial cultures of urine, blood, and throat, and administer appropriate antibiotics. 2, 3 Chest X-ray should be obtained if clinically indicated. 2

Fluid Resuscitation Protocol

Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg body weight/hour (approximately 1-1.5 L in average adult) during the first hour to restore circulatory volume and tissue perfusion. 2, 3, 4

• Total fluid replacement should correct estimated deficits (typically 6L or 100 mL/kg) within 24 hours 3
• Total fluid replacement should be approximately 1.5 times the 24-hour maintenance requirements 2
• Continue fluid replacement with induced change in serum osmolality not exceeding 3 mOsm/kg/hour 4
• Balanced electrolyte solutions may achieve faster DKA resolution than 0.9% saline, though isotonic saline remains standard 1

Monitor fluid input/output, hemodynamic parameters, and clinical examination continuously to assess progress. 4

Insulin Therapy: British vs. American Approach

British Guidelines Approach (JBDS-aligned)

The British guidelines recommend using subcutaneous insulin glargine (basal insulin analog) alongside continuous IV regular insulin from the start of treatment, which has demonstrated faster DKA resolution and shorter hospital stays compared to IV insulin alone. 1

Standard IV Insulin Protocol

• Administer IV bolus of regular insulin at 0.1-0.15 units/kg body weight 3, 4
• Follow with continuous infusion at 0.1 units/kg/hour 2, 3, 4
• If plasma glucose does not fall by 50 mg/dL from initial value in the first hour, double the insulin infusion every hour until steady glucose decline of 50-75 mg/hour is achieved 4
• Continue insulin infusion until DKA resolves: glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L 3, 4

Critical pitfall: Do not start insulin if potassium is <3.3 mEq/L, as this is the absolute cutoff to prevent life-threatening cardiac arrhythmias and death. 2 Continue aggressive potassium repletion until K+ ≥3.3 mEq/L before initiating insulin. 2

Potassium Management Algorithm

Total body potassium is depleted despite potentially normal or elevated initial serum levels due to acidosis-induced extracellular shift. 3, 4

• Once renal function is assured (adequate urine output confirmed), add 20-40 mEq/L potassium to IV fluids when serum levels fall below 5.5 mEq/L 2, 4
• Use combination of 2/3 KCl (or potassium-acetate) and 1/3 KPO4 2, 4
• Target serum potassium concentration of 4-5 mEq/L 4
• Monitor serum potassium closely as insulin therapy drives potassium intracellularly 2
• Obtain electrocardiogram to assess for cardiac effects of hypokalemia 2

If significant hypokalemia (<3.3 mEq/L) is present initially, delay insulin treatment until potassium concentration is restored to >3.3 mEq/L to avoid arrhythmias, cardiac arrest, and respiratory muscle weakness. 4

Monitoring Protocol

Check blood glucose every 2-4 hours while patient is fasting. 2, 4

Draw blood every 2-4 hours to determine:

• Serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality 2, 4
• Venous pH (typically 0.03 units lower than arterial pH) and anion gap to monitor resolution of acidosis 4

Target blood glucose levels of 100-180 mg/dL. 4

Continuous cardiac monitoring is crucial in severe DKA to detect arrhythmias early. 4

Bicarbonate Therapy: Generally Not Recommended

Bicarbonate therapy is generally not recommended in DKA patients with pH >7.0, as studies have failed to show beneficial effects on clinical outcomes. 4

Exceptions where bicarbonate may be considered:

• For adult patients with pH <6.9: administer 100 mmol sodium bicarbonate in 400 mL sterile water at 200 mL/hour 4
• For patients with pH 6.9-7.0: administer 50 mmol sodium bicarbonate in 200 mL sterile water at 200 mL/hour 4
• Pre- and post-intubation when serum pH <7.2 and/or bicarbonate <10 mEq/L to prevent metabolic acidosis and hemodynamic collapse from apnea during intubation 1

Avoid bicarbonate due to potential for worsening ketosis, hypokalemia, and increased risk of cerebral edema. 1

Phosphate Replacement

Studies have failed to show beneficial effects of routine phosphate replacement on clinical outcomes in DKA. 4

Consider phosphate replacement only in patients with:

• Cardiac dysfunction 4
• Anemia 4
• Respiratory depression 4
• Serum phosphate <1.0 mg/dL 4

Transition to Subcutaneous Insulin: Critical Timing

When DKA resolves (glucose <200 mg/dL, bicarbonate ≥18 mEq/L, venous pH >7.3, anion gap ≤12 mEq/L) and patient can eat, administer basal insulin (glargine or detemir) 2-4 hours BEFORE stopping the IV insulin infusion to prevent recurrence of ketoacidosis and rebound hyperglycemia. 2, 4, 1

• Transition to multiple-dose insulin schedule using combination of short/rapid-acting and intermediate/long-acting insulin 2, 4
• For newly diagnosed patients, initiate multidose regimen at approximately 0.5-1.0 units/kg/day 4

Do not stop IV insulin without prior basal insulin administration—this is the most common error leading to DKA recurrence. 2

Special Considerations for Mild DKA

For uncomplicated mild DKA in emergency department or step-down units:

• Subcutaneous rapid-acting insulin analogs may be used with aggressive fluid management, which may be safer and more cost-effective than IV insulin 1
• Subcutaneous regular insulin may be given every 4 hours (5-unit increments for every 50 mg/dL increase in blood glucose above 150 mg/dL, up to 20 units for blood glucose of 300 mg/dL) 4
• Fluid replacement at 1.5 times the 24-hour maintenance requirements (5 mL/kg/hour); do not exceed twice the maintenance requirement 4

Identifying and Treating Precipitating Causes

Common precipitating factors include:

• Infection (most common) 3
• New-onset diabetes 3
• Insulin omission 3
• Drugs affecting carbohydrate metabolism: corticosteroids, thiazides, sympathomimetic agents 3
• SGLT2 inhibitors causing euglycemic DKA 4, 1
• Myocardial infarction, stroke, or other acute stressors 1

SGLT2 inhibitors should be discontinued 3-4 days before surgery to prevent DKA. 4, 1

Cerebral Edema Prevention and Management

Cerebral edema is a rare but frequently fatal complication occurring in 0.7-1.0% of children with DKA, though it occurs more commonly in children and adolescents than adults. 4, 6

Risk factors for cerebral edema include:

• Severity of acidosis 7
• Greater hypocapnia (after adjusting for degree of acidosis) 7
• Higher blood urea nitrogen concentration at presentation 7, 1
• Treatment with bicarbonate 7
• Rapid overcorrection of hyperglycemia with fluids and insulin 1

Prevention strategies: Follow recommendations for gradual correction of glucose and osmolality, use judicious isotonic or hypotonic saline, and avoid hyperglycemia overcorrection. 4, 1

Airway Management in Critically Ill Patients

For impending respiratory failure, Bilevel positive airway pressure is not recommended due to aspiration risks. 1

Instead, use intubation and mechanical ventilation with monitoring and management of acid-base and fluid status. 1

Nutritional Support

Early initiation of oral nutrition has been shown to reduce intensive care unit and overall hospital length of stay. 1

Discharge Planning

Structured discharge planning should begin at admission and include:

• Patient education on insulin administration 2
• Glucose monitoring 2
• Sick day management 2
• Recognition, prevention, and management of DKA to prevent recurrence and readmission 4