What is the management approach for a patient with Diabetic Ketoacidosis (DKA), assumed to have a history of diabetes?

Management of Diabetic Ketoacidosis (DKA)

Begin immediate treatment with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour (approximately 1-1.5 L in the first hour) and continuous IV regular insulin at 0.1 units/kg/hour for moderate-to-severe DKA, while simultaneously identifying and treating precipitating factors. 1, 2

Initial Assessment and Diagnosis

Confirm DKA diagnosis with: blood glucose >250 mg/dL, arterial pH <7.3, serum bicarbonate <15 mEq/L, and presence of ketonemia or ketonuria 1

Obtain comprehensive laboratory evaluation:

• Plasma glucose, blood urea nitrogen/creatinine, serum ketones, electrolytes with calculated anion gap, osmolality 1, 2
• Arterial blood gases, complete blood count with differential, urinalysis with urine ketones 1
• Electrocardiogram to assess for cardiac complications and monitor potassium effects 1
• Direct measurement of β-hydroxybutyrate is preferred over nitroprusside method (which only measures acetoacetic acid and acetone) 1

Identify precipitating factors immediately: infection (obtain bacterial cultures from urine, blood, throat if suspected), myocardial infarction, cerebrovascular accident, pancreatitis, trauma, insulin omission/inadequacy, SGLT2 inhibitor use, or alcohol abuse 1, 2

Fluid Resuscitation Protocol

First hour: Administer isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour to restore intravascular volume and renal perfusion 1, 2

Subsequent fluid management depends on corrected serum sodium:

• If corrected sodium is normal or elevated: use 0.45% NaCl at 4-14 mL/kg/hour 2
• If corrected sodium is low: continue 0.9% NaCl 2

Critical transition point: When serum glucose reaches 200-250 mg/dL, switch to 5% dextrose with 0.45-0.75% NaCl while continuing insulin infusion 1, 2

• This prevents hypoglycemia while ensuring complete ketoacidosis resolution 1
• Common pitfall: Failure to add dextrose at this point leads to persistent ketoacidosis if insulin is stopped prematurely 1

Total fluid replacement should correct estimated deficits within 24 hours 1

Insulin Therapy

For Moderate-to-Severe DKA or Critically Ill Patients

Standard protocol: Continuous IV regular insulin at 0.1 units/kg/hour (no initial bolus recommended to reduce hypoglycemia risk) 1, 3

Target glucose decline: 50-75 mg/dL per hour 1

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

• Check hydration status first 1
• If hydration is adequate, double the insulin infusion rate hourly until steady decline achieved 1

Continue insulin infusion until complete DKA resolution (pH >7.3, bicarbonate ≥18 mEq/L, anion gap ≤12 mEq/L) regardless of glucose levels 1

• Critical point: Ketoacidosis may persist even after glucose normalizes 4
• Target glucose 150-200 mg/dL until resolution parameters met 1

Alternative Approach for Mild-to-Moderate Uncomplicated DKA

For hemodynamically stable, alert patients: Subcutaneous rapid-acting insulin analogs combined with aggressive fluid management are equally effective, safer, and more cost-effective than IV insulin 1

• This requires adequate fluid replacement, frequent point-of-care glucose monitoring, and treatment of concurrent infections 1
• Continuous IV insulin remains mandatory for critically ill and mentally obtunded patients 1

Potassium Management (Critical for Preventing Mortality)

Before starting insulin, check serum potassium:

If K+ <3.3 mEq/L:

• HOLD insulin therapy immediately 1
• Aggressively replace potassium until ≥3.3 mEq/L to prevent life-threatening arrhythmias and respiratory muscle weakness 1
• Total body potassium depletion averages 3-5 mEq/kg body weight despite initial serum levels 1

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

If K+ >5.5 mEq/L:

• Withhold potassium initially but monitor closely 1
• Levels will drop rapidly with insulin therapy (insulin drives potassium intracellularly) 1

Monitor potassium every 2-4 hours during active treatment 1

• Inadequate potassium monitoring and replacement is a leading cause of mortality in DKA 1

Bicarbonate Therapy (Generally NOT Recommended)

Do NOT administer bicarbonate for pH >6.9-7.0 1, 2

• Multiple studies show no difference in resolution of acidosis or time to discharge 1, 2
• Bicarbonate may worsen ketosis, cause hypokalemia, and increase cerebral edema risk 1

Monitoring During Treatment

Blood glucose: Every 1-2 hours until stable 2

Comprehensive metabolic panel: Every 2-4 hours to assess serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH 1, 2

Follow venous pH (typically 0.03 units lower than arterial pH) and anion gap to monitor acidosis resolution 1

Watch for cerebral edema signs: Altered mental status, headache, neurological deterioration (more common in children and adolescents) 1

DKA Resolution Criteria

All four parameters must be met:

• Glucose <200 mg/dL 1, 2
• Serum bicarbonate ≥18 mEq/L 1, 2
• Venous pH >7.3 1, 2
• Anion gap ≤12 mEq/L 1, 2

Transition to Subcutaneous Insulin

Critical timing: Administer basal insulin (intermediate or long-acting such as glargine or detemir) 2-4 hours BEFORE stopping IV insulin infusion 1, 2

• This prevents recurrence of ketoacidosis and rebound hyperglycemia 1, 2
• Major pitfall: Stopping IV insulin without prior basal insulin administration causes rebound hyperglycemia and ketoacidosis 1

If patient can eat: Start multiple-dose schedule using combination of short/rapid-acting and intermediate/long-acting insulin 1

If patient remains NPO: Continue IV insulin and fluid replacement, supplement with subcutaneous regular insulin as needed 1

Consider adding low-dose basal insulin analog during IV insulin infusion to prevent rebound hyperglycemia without increasing hypoglycemia risk 1

Special Considerations and Pitfalls

SGLT2 inhibitors:

• Discontinue immediately and do not restart until infection resolved and patient metabolically stable 1
• Must be discontinued 3-4 days before any planned surgery to prevent euglycemic DKA 1

Avoid overly rapid osmolality correction: Not exceeding 3 mOsm/kg/h to prevent cerebral edema 4

In patients with cardiac dysfunction or pleural effusions: Avoid excessive fluid administration which may worsen pulmonary edema 4

Pregnancy and chronic kidney disease: Require tailored management strategies with more cautious fluid and electrolyte management 5

Discharge Planning

Before discharge, ensure:

• Identification of outpatient diabetes care providers 1
• Patient/family education on glucose monitoring, insulin administration, recognition and treatment of hyperglycemia/hypoglycemia 1
• Understanding of precipitating factors and how to prevent recurrence 1
• Follow-up appointments scheduled prior to discharge 1