What are the treatment guidelines for a patient presenting with Diabetic Ketoacidosis (DKA)?

Treatment Guidelines for Diabetic Ketoacidosis (DKA)

Begin immediate treatment with isotonic saline at 15-20 mL/kg/hour for the first hour, followed by continuous IV regular insulin at 0.1 units/kg/hour, while aggressively monitoring and replacing potassium to maintain levels between 4-5 mEq/L. 1, 2

Initial Diagnostic Criteria and Assessment

DKA is confirmed when all three criteria are present: 1

• Blood glucose >250 mg/dL
• Arterial pH <7.3 and serum bicarbonate <15 mEq/L
• Presence of ketonemia or ketonuria

Obtain the following laboratory studies immediately: 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 with urine ketones
• Electrocardiogram with continuous cardiac monitoring 2
• Direct measurement of β-hydroxybutyrate in blood is preferred over nitroprusside method 1, 2

Identify precipitating factors immediately: infection (obtain cultures of blood, urine, throat), myocardial infarction, stroke, pancreatitis, trauma, insulin omission, or SGLT2 inhibitor use 1, 2

Fluid Resuscitation Protocol

First Hour: 1, 2

• Administer isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour (approximately 1-1.5 L in average adult)
• Balanced electrolyte solutions may be preferred over 0.9% saline to reduce hyperchloremic acidosis risk 2

Subsequent Fluid Management: 1, 2

• Continue fluid replacement based on hydration status, electrolyte levels, and urine output
• When glucose reaches 200-250 mg/dL, switch to 5% dextrose with 0.45-0.75% saline while continuing insulin infusion 1, 2
• Correct total estimated fluid deficit within 24 hours
• Do not allow serum osmolality to change by more than 3 mOsm/kg/hour to prevent cerebral edema 2

Insulin Therapy

For Moderate-to-Severe DKA or Critically Ill Patients: 1, 2

• Start continuous IV regular insulin at 0.1 units/kg/hour (standard of care)
• Optional: Give initial IV bolus of 0.1-0.15 units/kg 1, 2
• Target glucose decline of 50-75 mg/dL per hour 1
• If glucose does not fall by 50 mg/dL in first hour, check hydration status; if adequate, double insulin infusion hourly until target decline achieved 1

For Mild-to-Moderate Uncomplicated DKA (Hemodynamically Stable, Alert Patients): 1, 2

• Subcutaneous rapid-acting insulin analogs at 0.15 units/kg every 2-3 hours combined with aggressive fluid management are equally effective, safer, and more cost-effective than IV insulin 1, 2
• This approach requires adequate fluid replacement, frequent point-of-care glucose monitoring, and treatment of concurrent infections 1

Critical Insulin Management Points: 1

• 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 stop insulin when glucose falls below 250 mg/dL—this is when dextrose must be added to IV fluids 1
• Target glucose 150-200 mg/dL until DKA resolution parameters are met 1, 2

Potassium Management (Critical for Preventing Mortality)

This is the most dangerous electrolyte abnormality in DKA—total body potassium depletion averages 3-5 mEq/kg despite potentially normal or elevated initial levels. 1, 2

If K+ <3.3 mEq/L: 1

• DO NOT start insulin therapy
• Aggressively replace potassium until levels reach ≥3.3 mEq/L
• Failure to correct can cause life-threatening arrhythmias, cardiac arrest, and respiratory muscle weakness

If K+ 3.3-5.5 mEq/L: 1, 2

• Add 20-40 mEq potassium per liter of IV fluid once adequate urine output confirmed
• Use 2/3 KCl and 1/3 KPO₄ 1
• Target serum potassium 4-5 mEq/L throughout treatment 1

If K+ >5.5 mEq/L: 1

• Withhold potassium initially but monitor closely every 2-4 hours
• Levels will drop rapidly with insulin therapy and fluid resuscitation

Bicarbonate Therapy

Bicarbonate is NOT recommended for pH >6.9-7.0. 1, 2 Multiple studies show:

• No difference in resolution of acidosis or time to discharge
• May worsen ketosis and cause hypokalemia
• Increases cerebral edema risk, particularly in children 1, 2

Only for pH <6.9: 2

• Administer 100 mmol sodium bicarbonate in 400 mL sterile water at 200 mL/hour

For pH 6.9-7.0: 2

• Administer 50 mmol sodium bicarbonate in 200 mL sterile water at 200 mL/hour

Monitoring Protocol

Every 2-4 hours, obtain: 1, 2

• Serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality
• Venous pH (typically 0.03 units lower than arterial pH) and anion gap 1
• Blood β-hydroxybutyrate levels (preferred over urine ketones) 1, 2

Continuous monitoring: 2

• Cardiac monitoring for arrhythmias (especially with potassium abnormalities)
• Fluid input/output and hemodynamic parameters
• Point-of-care glucose monitoring

Resolution Criteria

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

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

Transition to Subcutaneous Insulin

This is a critical step where errors commonly occur. 1, 2

Administer basal insulin (glargine, detemir, or NPH) 2-4 hours BEFORE stopping IV insulin infusion to prevent recurrence of ketoacidosis and rebound hyperglycemia 1, 2

Once patient can eat: 1, 2

• Start multiple-dose regimen with combination of short/rapid-acting and intermediate/long-acting insulin
• For newly diagnosed patients: 0.5-1.0 units/kg/day 2

If patient remains NPO after DKA resolution: 1

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

Emerging evidence: Adding low-dose basal insulin analog during IV insulin infusion may prevent rebound hyperglycemia without increasing hypoglycemia risk 1, 2

Special Considerations and Precipitating Factors

SGLT2 Inhibitors: 1, 2

• Can cause euglycemic DKA (normal glucose with ketoacidosis)
• Discontinue immediately and do not restart until 3-4 days after metabolic stability achieved
• Must be stopped 3-4 days before any planned surgery

Infection Management: 1, 2

• Obtain bacterial cultures (blood, urine, throat) if suspected
• Administer appropriate antibiotics immediately
• Treat concurrently with DKA management

Cardiovascular Events: 1

• Myocardial infarction can both precipitate and be masked by DKA
• Stroke can precipitate DKA—assess for focal neurological deficits
• Obtain ECG and monitor for cardiac complications

Pregnancy, Renal Disease, Heart Failure: 3

• Require more cautious fluid administration
• Consider nephrology consultation if anuric or oliguric 1

Critical Pitfalls to Avoid

Most common errors leading to complications or prolonged DKA: 1

1. Stopping insulin when glucose falls below 250 mg/dL instead of adding dextrose to IV fluids
2. Failing to administer basal insulin 2-4 hours before stopping IV insulin, causing rebound hyperglycemia and ketoacidosis recurrence
3. Starting insulin therapy with K+ <3.3 mEq/L, risking fatal arrhythmias
4. Inadequate potassium monitoring and replacement—check every 2-4 hours during active treatment
5. Premature termination of insulin before complete resolution of ketosis (must meet all four resolution criteria)
6. Overly rapid correction of osmolality (>3 mOsm/kg/hour), increasing cerebral edema risk, especially in children

Cerebral Edema Warning

Cerebral edema is rare (0.7-1.0% in children) but frequently fatal. 2 Risk factors include: 2

• Higher BUN at presentation
• Overly aggressive fluid resuscitation
• Rapid osmolality correction
• More common in children and adolescents than adults 1

Monitor closely for: altered mental status, headache, neurological deterioration 1

Discharge Planning

Before discharge, ensure: 1, 2

• Identification of outpatient diabetes care providers
• Education on glucose monitoring, insulin administration, recognition of hyperglycemia/hypoglycemia
• Understanding of precipitating factors and how to prevent recurrence
• Appropriate insulin regimen prescribed with attention to medication access and affordability 1
• Follow-up appointment scheduled within 1-2 weeks 4