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

JBDS Guidelines on Diabetic Ketoacidosis Management

While the evidence provided primarily reflects American Diabetes Association (ADA) guidelines rather than JBDS (Joint British Diabetes Societies) specifically, the British approach notably differs by recommending subcutaneous basal insulin (glargine) alongside continuous IV insulin, which has demonstrated faster DKA resolution and shorter hospital stays compared to IV insulin alone. 1

Diagnostic Criteria

DKA is diagnosed when the following are present:

• Blood glucose >250 mg/dL (though euglycemic DKA is increasingly recognized) 2
• Arterial pH <7.3 2
• Serum bicarbonate <15 mEq/L 2
• Presence of ketonemia or ketonuria 2
• Anion gap >10 mEq/L 3

Direct measurement of β-hydroxybutyrate in blood is the preferred monitoring method, as nitroprusside only detects acetoacetic acid and acetone, missing the primary ketone body. 4

Initial Assessment and Laboratory Evaluation

Obtain immediately:

• Plasma glucose, serum ketones (β-hydroxybutyrate preferred) 2, 4
• Electrolytes with calculated anion gap, serum osmolality 2
• Blood urea nitrogen, creatinine (assess renal function and dehydration) 2
• Arterial or venous blood gas (venous pH typically 0.03 units lower than arterial) 2, 4
• Complete blood count with differential 2
• Urinalysis and urine ketones 2
• Electrocardiogram (essential for detecting arrhythmias from electrolyte shifts) 4
• If infection suspected: blood cultures, urine cultures, throat cultures 2

Identify precipitating factors: infection (most common), myocardial infarction, stroke, pancreatitis, trauma, insulin omission, SGLT2 inhibitor use, alcohol abuse. 2, 4

Fluid Resuscitation

Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour (approximately 1-1.5 L) during the first hour to restore intravascular volume and tissue perfusion. 2, 4 Some evidence supports balanced electrolyte solutions showing faster DKA resolution, though normal saline remains standard. 1

Subsequent fluid management:

• Continue fluid replacement based on hydration status, electrolyte levels, and urine output 2
• When glucose reaches 200-250 mg/dL, switch to 5% dextrose with 0.45-0.75% saline while continuing insulin infusion to prevent hypoglycemia and ensure complete ketone clearance 2, 4
• Aim to correct estimated fluid deficits within 24 hours 2
• Limit osmolality correction to <3 mOsm/kg/hour to prevent cerebral edema 4, 5

Insulin Therapy

Standard Approach (Critically Ill Patients)

Continuous IV regular insulin at 0.1 units/kg/hour is the standard of care for critically ill and mentally obtunded patients. 2, 4 An initial bolus of 0.15 U/kg may be given, though some guidelines recommend starting infusion without bolus. 4

Critical prerequisite: Do NOT start insulin if serum potassium <3.3 mEq/L—aggressively replace potassium first to prevent life-threatening arrhythmias and respiratory muscle weakness. 2

Insulin adjustment:

• If 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 steady decline of 50-75 mg/dL/hour 2, 4
• Target glucose 150-200 mg/dL until DKA resolution 2
• Continue insulin infusion until complete resolution of ketoacidosis regardless of glucose levels—this is a common pitfall where premature insulin cessation causes recurrent DKA 2

British Approach (Distinctive Feature)

British guidelines recommend adding subcutaneous basal insulin (glargine) alongside continuous IV insulin, which has shown faster DKA resolution and shorter hospital stays compared to IV insulin alone. 1 This approach helps prevent rebound hyperglycemia. 2

Alternative for Mild-Moderate Uncomplicated DKA

For uncomplicated mild-moderate DKA, subcutaneous rapid-acting insulin analogs combined with aggressive fluid management are equally effective, safer, and more cost-effective than IV insulin. 2, 4 This requires:

• Adequate fluid replacement 2
• Frequent point-of-care glucose monitoring 2
• Emergency department or step-down unit setting 4
• Patient not critically ill or mentally obtunded 2

Electrolyte Management

Potassium (Critical—Leading Cause of DKA Mortality if Mismanaged)

Despite potentially normal or elevated initial levels, total body potassium depletion is universal in DKA, and insulin therapy will further lower serum potassium. 2, 4

Management algorithm:

• If K+ <3.3 mEq/L: DELAY insulin therapy and aggressively replace potassium until ≥3.3 mEq/L 2
• If K+ 3.3-5.5 mEq/L: Add 20-30 mEq potassium per liter of IV fluid (use 2/3 KCl and 1/3 KPO₄) once adequate urine output confirmed 2, 4
• If K+ >5.5 mEq/L: Withhold potassium initially but monitor closely—levels will drop rapidly with insulin therapy 2, 4
• Target serum potassium 4-5 mEq/L throughout treatment 2, 4

Bicarbonate (Generally NOT Recommended)

Bicarbonate is NOT recommended for DKA patients with pH >6.9-7.0, as multiple studies show no difference in resolution of acidosis or time to discharge. 2, 4 Bicarbonate may worsen ketosis, cause hypokalemia, and increase cerebral edema risk. 2, 4

Exception: Consider bicarbonate only if:

• pH <6.9: Give 100 mmol sodium bicarbonate in 400 mL sterile water at 200 mL/h 4
• pH 6.9-7.0: Give 50 mmol sodium bicarbonate in 200 mL sterile water at 200 mL/h 4
• Pre/post-intubation with pH <7.2 to prevent hemodynamic collapse from apnea 1

Phosphate

Routine phosphate replacement has failed to show beneficial effects on clinical outcomes. 4 Consider replacement only if:

• Cardiac dysfunction present 4
• Anemia or respiratory depression 4
• Serum phosphate <1.0 mg/dL 4

Monitoring During Treatment

Draw blood every 2-4 hours to determine:

• Serum electrolytes (especially potassium) 2, 4
• Glucose 2, 4
• Blood urea nitrogen, creatinine 2, 4
• Osmolality 2, 4
• Venous pH and anion gap 2, 4

Monitor glucose every 1-2 hours until stable, then every 4 hours. 5

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

Resolution Criteria

DKA is resolved when ALL of the following are met:

• Glucose <200 mg/dL 2, 4
• Serum bicarbonate ≥18 mEq/L 2, 4
• Venous pH >7.3 2, 4
• Anion gap ≤12 mEq/L 2, 4

Transition to Subcutaneous Insulin

This is a critical step where errors commonly occur:

Administer basal insulin (intermediate or long-acting) 2-4 hours BEFORE stopping IV insulin infusion to prevent recurrence of ketoacidosis and rebound hyperglycemia. 2, 4 This overlap period is essential. 2

Once patient can eat:

• Start multiple-dose schedule using combination of short/rapid-acting and intermediate/long-acting insulin 2, 4
• For newly diagnosed patients: approximately 0.5-1.0 units/kg/day 4

If patient remains NPO after DKA resolution:

• Continue IV insulin and fluid replacement 2
• Supplement with subcutaneous regular insulin as needed 2

Special Considerations

SGLT2 Inhibitors

Discontinue SGLT2 inhibitors 3-4 days before any planned surgery to prevent euglycemic DKA. 2, 4 These medications modestly increase DKA risk and can cause euglycemic DKA where glucose may not be markedly elevated. 3

Cerebral Edema (Rare but Fatal Complication)

Occurs in 0.7-1.0% of children with DKA but is rare in adults. 4 Risk factors include:

• Higher BUN at presentation 4
• Rapid correction of hyperglycemia and osmolality 4, 5
• Excessive hypotonic fluid administration 4

Prevention strategies:

• Limit osmolality correction to <3 mOsm/kg/hour 4, 5
• Avoid excessive fluid administration in cardiac dysfunction 5
• In children: use 1.5 times maintenance requirements (5 mL/kg/h), not exceeding twice maintenance 4

Airway Management

For impending respiratory failure:

• BiPAP is NOT recommended due to aspiration risk 1
• Intubation and mechanical ventilation are recommended with careful monitoring of acid-base and fluid status 1
• Consider bicarbonate pre/post-intubation if pH <7.2 to prevent hemodynamic collapse 1

Common Pitfalls to Avoid

• Premature termination of insulin before complete ketosis resolution—continue insulin until all resolution criteria met, not just glucose normalization 2
• Interrupting insulin infusion when glucose falls—add dextrose instead and continue insulin to clear ketones 2
• Failure to add dextrose when glucose <250 mg/dL—this leads to hypoglycemia while ketones persist 2
• Inadequate potassium monitoring and replacement—leading cause of DKA mortality 2
• Starting insulin with K+ <3.3 mEq/L—can cause fatal arrhythmias 2
• Stopping IV insulin without prior basal insulin administration—causes rebound hyperglycemia and recurrent DKA 2, 4
• Overly rapid osmolality correction—increases cerebral edema risk 4, 5

Discharge Planning

Before discharge, ensure:

• Identification of outpatient diabetes care providers 2
• Patient education on diabetes diagnosis, glucose monitoring, home glucose goals 2
• Instructions on when to call healthcare professional 2
• Recognition, prevention, and management of DKA to prevent recurrence 4
• Structured discharge plan tailored to reduce readmission rates 4, 5