What is the typical management for Diabetic Ketoacidosis (DKA)?

Management of Diabetic Ketoacidosis

Begin immediate fluid resuscitation with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour during the first hour, followed by continuous intravenous regular insulin at 0.1 units/kg/hour once adequate hydration and potassium levels are confirmed. 1, 2

Initial Assessment and Diagnosis

Confirm DKA diagnosis with the following laboratory criteria: 1, 2

• Blood glucose >250 mg/dL
• Arterial pH <7.30
• Serum bicarbonate <18 mEq/L (some guidelines use <15 mEq/L)
• Positive serum and urine ketones

Obtain comprehensive laboratory evaluation including: 1, 2

• Plasma glucose, blood urea nitrogen/creatinine, serum ketones
• Electrolytes with calculated anion gap and osmolality
• Arterial blood gases, complete blood count with differential
• Urinalysis, urine ketones, electrocardiogram
• Bacterial cultures (urine, blood, throat) if infection is suspected 3

Direct measurement of β-hydroxybutyrate in blood is the preferred method for monitoring ketosis, as the nitroprusside method only detects acetoacetic acid and acetone, missing the predominant ketone body. 2, 4

Fluid Therapy Protocol

First Hour

Administer isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour (approximately 1-1.5 L in average adults) to restore intravascular volume and renal perfusion. 3, 1, 2

Subsequent Fluid Management

After initial resuscitation, fluid choice depends on corrected serum sodium: 3

• If corrected sodium is normal or elevated: use 0.45% NaCl at 4-14 mL/kg/hour
• If corrected sodium is low: continue 0.9% NaCl at similar rate
• Correct serum sodium for hyperglycemia by adding 1.6 mEq to sodium value for each 100 mg/dL glucose above 100 mg/dL 3

When serum glucose reaches 250 mg/dL, switch to 5% dextrose with 0.45-0.75% NaCl while continuing insulin infusion to prevent hypoglycemia and ensure complete ketoacidosis resolution. 1, 2, 4

Total fluid replacement should correct estimated deficits within 24 hours, with osmolality changes not exceeding 3 mOsm/kg H₂O per hour. 3

Insulin Therapy

Do NOT start insulin if serum potassium is <3.3 mEq/L—aggressively replace potassium first to prevent life-threatening cardiac arrhythmias and respiratory muscle weakness. 1, 2

Standard Insulin Protocol

Start continuous intravenous regular insulin infusion at 0.1 units/kg/hour without an initial bolus. 1, 2, 4

If plasma glucose does not fall by 50 mg/dL in the first hour: 1

• Check hydration status
• If acceptable, double the insulin infusion rate hourly until steady glucose decline of 50-75 mg/hour is achieved

Continue insulin infusion until complete resolution of ketoacidosis (pH >7.3, bicarbonate ≥18 mEq/L, anion gap ≤12 mEq/L) regardless of glucose levels—never interrupt insulin when glucose falls. 1, 2, 4

Alternative for Mild-Moderate Uncomplicated DKA

For hemodynamically stable, alert patients with mild-moderate DKA, subcutaneous rapid-acting insulin analogs combined with aggressive fluid management are equally effective, safer, and more cost-effective than IV insulin. 1, 2 However, continuous IV insulin remains standard for critically ill and mentally obtunded patients. 1, 2

Electrolyte Management

Potassium Replacement (Critical)

Despite often presenting with normal or elevated potassium, total body potassium depletion is universal in DKA, and insulin therapy will rapidly lower serum levels. 1, 2

Follow this algorithm: 1, 2

• If K⁺ <3.3 mEq/L: Hold insulin, aggressively replace potassium until ≥3.3 mEq/L
• If K⁺ 3.3-5.5 mEq/L: Add 20-30 mEq/L potassium to IV fluids (use 2/3 KCl and 1/3 KPO₄) once adequate urine output confirmed
• If K⁺ >5.5 mEq/L: Withhold potassium initially but monitor closely as levels will drop rapidly with insulin

Target serum potassium of 4-5 mEq/L throughout treatment. 1, 2

Bicarbonate Administration

Bicarbonate is NOT recommended for DKA patients with pH >6.9-7.0, as studies show no benefit in resolution time or outcomes, and it may worsen ketosis, cause hypokalemia, and increase cerebral edema risk. 1, 2, 4 Consider bicarbonate only if pH <6.9 or in peri-intubation period to prevent hemodynamic collapse. 5

Phosphate

Include phosphate replacement (as part of potassium replacement using KPO₄) to prevent potential complications, though routine aggressive phosphate replacement is not required. 3

Monitoring During Treatment

Check blood glucose every 1-2 hours. 1, 4

Draw blood every 2-4 hours to assess: 1, 2, 4

• Serum electrolytes, glucose, blood urea nitrogen, creatinine
• Osmolality and venous pH (typically 0.03 units lower than arterial pH)
• Anion gap to monitor resolution of acidosis

Monitor for signs of cerebral edema, particularly in pediatric patients, as overly rapid correction of osmolality increases risk. 3, 2

Resolution Criteria

DKA is resolved when ALL of the following are met: 1, 2, 4

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

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, 4 Recent evidence suggests adding low-dose basal insulin analog during IV insulin infusion may prevent rebound hyperglycemia without increasing hypoglycemia risk. 1, 2

Once the patient can eat, start a multiple-dose schedule using combination of short/rapid-acting and intermediate/long-acting insulin. 2

Treatment of Precipitating Causes

Identify and treat underlying triggers concurrently: 3, 1, 2

• Infections (most common)—obtain cultures and administer appropriate antibiotics
• Myocardial infarction, stroke, pancreatitis, trauma
• Insulin omission or inadequacy
• SGLT2 inhibitors—discontinue 3-4 days before any planned surgery to prevent euglycemic DKA 1

Common Pitfalls to Avoid

Premature termination of insulin therapy before complete resolution of ketosis is a leading cause of DKA recurrence. 2, 4 Continue insulin until all resolution criteria are met, not just glucose normalization.

Inadequate potassium monitoring and replacement is a leading cause of mortality in DKA. 1, 2 Check levels frequently and maintain aggressive replacement.

Failure to add dextrose when glucose falls below 250 mg/dL while continuing insulin leads to hypoglycemia and persistent ketoacidosis. 2, 4 Always add dextrose-containing fluids at this threshold.

Interrupting insulin infusion when glucose levels fall without adding dextrose perpetuates ketoacidosis. 2, 4

Overzealous fluid administration in pediatric patients (<20 years) increases cerebral edema risk—limit initial reexpansion to 50 mL/kg over first 4 hours. 3