What is the management of Diabetic Ketoacidosis (DKA)?

From the Guidelines

Diabetic ketoacidosis (DKA) management requires prompt intervention with intravenous fluids, insulin therapy, and electrolyte replacement, with the goal of restoring circulatory volume, resolving ketoacidosis, and correcting electrolyte imbalance and acidosis, as recommended in the most recent guidelines 1.

Key Components of DKA Management

• Begin with 1-2 liters of normal saline (0.9% NaCl) in the first 1-2 hours, followed by continued fluid replacement based on hydration status.
• Start an IV insulin infusion at 0.1 units/kg/hour after the initial fluid bolus, with the option to use subcutaneous rapid-acting insulin analogs in mild or moderate DKA cases 1.
• Monitor blood glucose hourly, aiming for a decrease of 50-75 mg/dL per hour, and adjust insulin infusion rate as needed.
• Replace potassium when levels are below 5.3 mEq/L and the patient is producing urine, typically with 20-30 mEq KCl per liter of IV fluid.
• Address other electrolyte abnormalities, particularly phosphate and magnesium, and monitor for resolution of DKA by checking for normalized anion gap, bicarbonate >15 mEq/L, pH >7.3, and improved mental status.

Transition to Subcutaneous Insulin

• Once DKA resolves, transition to subcutaneous insulin, giving the first dose 1-2 hours before stopping the insulin infusion, to prevent recurrence of ketoacidosis and rebound hyperglycemia 1.

Underlying Trigger Identification

• Identify and address the underlying trigger of DKA, which commonly includes infection, medication non-adherence, or new-onset diabetes, to prevent future episodes.

Continuous Monitoring

• Continuous monitoring of vital signs, mental status, fluid balance, and laboratory values is essential for successful management of DKA, as recommended in the guidelines 1.

From the FDA Drug Label

Hyperglycemia (too much glucose in the blood) may develop if your body has too little insulin Hyperglycemia can be brought about by any of the following: Omitting your insulin or taking less than your doctor has prescribed. In patients with type 1 or insulin-dependent diabetes, prolonged hyperglycemia can result in DKA (a life-threatening emergency) The first symptoms of DKA usually come on gradually, over a period of hours or days, and include a drowsy feeling, flushed face, thirst, loss of appetite, and fruity odor on the breath. With DKA, blood and urine tests show large amounts of glucose and ketones. Heavy breathing and a rapid pulse are more severe symptoms If uncorrected, prolonged hyperglycemia or DKA can lead to nausea, vomiting, stomach pain, dehydration, loss of consciousness, or death. Therefore, it is important that you obtain medical assistance immediately.

DKA Management requires immediate medical assistance. The first symptoms of DKA include:

• Drowsy feeling
• Flushed face
• Thirst
• Loss of appetite
• Fruity odor on the breath If uncorrected, DKA can lead to severe symptoms such as:
• Nausea
• Vomiting
• Stomach pain
• Dehydration
• Loss of consciousness
• Death It is crucial to obtain medical help immediately if DKA is suspected 2.

From the Research

DKA Management Overview

• Diabetic ketoacidosis (DKA) is a serious complication of diabetes that requires prompt diagnosis and treatment 3, 4, 5, 6.
• The pathogenesis of DKA involves insulin deficiency, leading to increased rates of hepatic ketogenesis and gluconeogenesis, resulting in hyperglycemia and ketonemia 3.

Treatment of DKA

• Treatment of DKA consists of insulin and fluid replacement, with insulin therapy titrated against the change in blood glucose concentration 3, 4, 5, 6.
• Isotonic saline is the initial replacement fluid, and potassium is administered as required 3, 5.
• Bicarbonate may be employed in extreme acidosis, but its administration may contribute to the development of hypokalemia, CSF acidosis, and tissue hypoxia 3, 5.

Fluid Management in DKA

• Recent studies suggest that large volumes of normal saline may lead to undesirable outcomes such as hyperchloremic metabolic acidosis 7.
• The use of balanced crystalloids, such as lactated Ringers, for initial resuscitation in DKA patients may reduce the risk of complications related to hyperchloremia and improve clinical outcomes 7.

Monitoring and Prevention of DKA

• Careful monitoring of glucose concentrations, vital signs, and electrolytes is essential to prevent complications arising from the treatment of DKA 4, 6.
• Prevention of DKA has been underemphasized in the care of the ill diabetic patient, and requires a knowledgeable physician and a cooperative patient 5.
• Patient education programs focusing on adherence to insulin and self-care guidelines during illness and improved access to medical providers can help reduce the risk of DKA recurrence 6.