What is the initial management for a patient presenting with Diabetic Ketoacidosis (DKA)?

SOAP Note for Diabetic Ketoacidosis (DKA)

Subjective

Chief Complaint & History of Present Illness:

• Document duration and progression of polyuria, polydipsia, nausea, vomiting, abdominal pain, and altered mental status 1
• Identify precipitating factors: recent infection (most common), new diabetes diagnosis, insulin omission/non-adherence, medication changes (especially SGLT2 inhibitors, corticosteroids, thiazides), myocardial infarction, stroke, pancreatitis, trauma, or alcohol abuse 1, 2
• Obtain insulin regimen details and recent adherence patterns 1
• Review sick-day management and recent illness 3

Past Medical History:

• Type 1 vs Type 2 diabetes history and control 1
• Previous DKA episodes 3
• Cardiac or renal disease (affects fluid management) 4

Objective

Initial Vital Signs & Physical Examination:

• Assess severity of dehydration: dry mucous membranes, poor skin turgor, hypotension, tachycardia (typical deficit: 6L or 100 ml/kg body weight) 4, 2
• Mental status: alert (mild DKA), drowsy (moderate), stupor/coma (severe) 5
• Respiratory pattern: Kussmaul respirations (deep, rapid breathing) 1
• Cardiac examination: assess for signs of myocardial infarction (can precipitate and be masked by DKA) 1
• Neurological examination: focal deficits suggesting stroke as precipitant 1
• Signs of infection: obtain cultures from urine, blood, throat if suspected 4, 2

Initial Laboratory Evaluation (STAT):

Diagnostic Criteria for DKA:

• Blood glucose >250 mg/dL 1, 5, 2
• Venous pH <7.3 1, 5, 2
• Serum bicarbonate <15 mEq/L 1, 5, 2
• Moderate ketonuria or ketonemia (β-hydroxybutyrate preferred over nitroprusside method) 1, 5

Severity Classification:

• Mild: pH 7.25-7.30, bicarbonate 15-18 mEq/L, alert 5
• Moderate: pH 7.00-7.24, bicarbonate 10-15 mEq/L, drowsy 5
• Severe: pH <7.00, bicarbonate <10 mEq/L, stupor/coma 5

Complete Metabolic Panel:

• Calculate anion gap: [Na+] - ([Cl-] + [HCO3-]), should be >10-12 mEq/L 5, 2
• Calculate corrected sodium: add 1.6 mEq/L for every 100 mg/dL glucose above 100 mg/dL 4, 1, 2
• Potassium level (critical: total body depletion of 3-5 mEq/kg despite potentially normal/elevated initial levels) 4, 1, 2
• BUN/creatinine, serum osmolality 4, 5

Additional Labs:

• β-hydroxybutyrate (gold standard for ketone measurement, not nitroprusside-based tests) 1, 5
• Complete blood count with differential 4, 2
• Arterial or venous blood gas 4, 5
• Urinalysis with urine ketones 4
• HbA1c (distinguishes acute vs chronic poor control) 4, 5
• Blood lactate (if lactic acidosis suspected) 5

Ancillary Studies:

• Electrocardiogram (assess for MI, monitor for hypokalemia changes) 4, 2
• Chest X-ray if respiratory symptoms present 4
• Bacterial cultures if infection suspected 4, 2

Assessment

Primary Diagnosis: Diabetic Ketoacidosis - [Mild/Moderate/Severe based on pH and bicarbonate] 5

Severity Stratification:

• pH <7.00 and bicarbonate <10 mEq/L indicates severe DKA requiring intensive monitoring 5

Precipitating Factor: [Identify specific cause: infection, insulin omission, new diagnosis, SGLT2 inhibitor use, MI, etc.] 1, 2

Differential Diagnosis to Exclude:

• Alcoholic ketoacidosis (glucose typically <250 mg/dL or hypoglycemic) 4
• Starvation ketosis (bicarbonate usually >18 mEq/L) 4
• Lactic acidosis 5
• Toxic ingestions (salicylate, methanol, ethylene glycol) 4, 5

Plan

1. Fluid Resuscitation

First Hour:

• Administer isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour (approximately 1-1.5 L in average adult) to restore circulatory volume and renal perfusion 4, 1, 2

Subsequent Fluid Management:

• If corrected sodium is normal or elevated: use 0.45% NaCl at 4-14 mL/kg/hour 4
• If corrected sodium is low: continue 0.9% NaCl at similar rate 4
• Target: correct estimated 6-9L deficit within 24 hours 4, 2
• When glucose reaches 250 mg/dL: change to 5% dextrose with 0.45-0.75% NaCl while continuing insulin to prevent hypoglycemia and allow complete ketone clearance 1, 5

Critical Monitoring:

• Monitor for fluid overload in patients with cardiac or renal compromise 4
• Change in serum osmolality should not exceed 3 mOsm/kg/h 4

2. Insulin Therapy

For Moderate-Severe DKA or Critically Ill/Obtunded Patients:

• Start continuous IV regular insulin at 0.1 units/kg/hour (standard of care) 1, 2
• No initial bolus required (per most recent guidelines) 1
• Target glucose decline: 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 rate hourly until steady decline achieved 1

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

• Alternative approach: subcutaneous rapid-acting insulin analogs at 0.15 units/kg every 2-3 hours combined with aggressive fluid management (equally effective, safer, more cost-effective) 1

Critical Rule:

• Continue insulin infusion until DKA resolution (pH >7.3, bicarbonate ≥18 mEq/L, anion gap ≤12 mEq/L) regardless of glucose levels 1
• Target glucose 150-200 mg/dL during treatment by adding dextrose, NOT by stopping insulin 1

3. Potassium Management

CRITICAL ALGORITHM:

If K+ <3.3 mEq/L:

• HOLD insulin therapy 1
• Aggressively replace potassium first until ≥3.3 mEq/L to prevent fatal cardiac arrhythmias 1

If K+ 3.3-5.5 mEq/L:

• Add 20-30 mEq/L potassium to each liter of IV fluid (use 2/3 KCl and 1/3 KPO4) once adequate urine output confirmed 4, 1, 2

If K+ >5.5 mEq/L:

• Withhold potassium initially but monitor closely every 2-4 hours, as levels will drop rapidly with insulin therapy 1

Target: maintain serum K+ between 4-5 mEq/L throughout treatment 1

4. Bicarbonate Therapy

The American Diabetes Association recommends AGAINST bicarbonate use for pH >6.9-7.0 1

• No benefit in resolution time or outcomes 1
• May worsen ketosis, cause hypokalemia, and increase cerebral edema risk 1
• Consider only if pH <6.9 1

5. Monitoring Protocol

Every 2-4 Hours:

• Serum electrolytes, glucose, BUN, creatinine, osmolality, venous pH 1, 5
• β-hydroxybutyrate (preferred over urine ketones) 1, 5
• Potassium levels (critical to prevent hypokalemia) 1

Avoid Pitfall:

• Do NOT use nitroprusside-based ketone tests for monitoring; they only measure acetoacetate/acetone, not β-hydroxybutyrate, and can falsely suggest worsening during treatment 1, 5

6. Resolution Criteria

DKA is resolved when ALL of the following are met:

• Glucose <200 mg/dL 1, 5
• Serum bicarbonate ≥18 mEq/L 1, 5
• Venous pH >7.3 1, 5
• Anion gap ≤12 mEq/L 1, 5

7. Transition to Subcutaneous Insulin

CRITICAL TIMING:

• Administer basal insulin (glargine or detemir) 2-4 hours BEFORE stopping IV insulin infusion to prevent recurrence of ketoacidosis and rebound hyperglycemia 1
• Once patient can eat, start multiple-dose schedule with combination of rapid-acting and long-acting insulin 1

Common Pitfall to Avoid:

• Stopping IV insulin when glucose normalizes causes recurrent ketoacidosis, as ketone clearance takes longer than glucose normalization 1

8. Treatment of Precipitating Cause

Concurrent Management:

• Administer appropriate antibiotics if infection identified 4, 2
• Treat myocardial infarction, stroke, or other precipitants 1
• Discontinue SGLT2 inhibitors immediately and do not restart until 3-4 days after metabolic stability achieved 1

9. Cerebral Edema Prevention

High-Risk Scenario (especially children/adolescents):

• Monitor closely for altered mental status, headache, neurological deterioration 1
• Avoid overly rapid correction of osmolality 4, 1

10. Discharge Planning

Before Discharge:

• Identify outpatient diabetes care providers 1
• Educate on glucose monitoring, insulin administration, sick-day management 1, 3
• Ensure appropriate insulin regimen prescribed with attention to medication access/affordability 1
• Teach recognition and prevention of DKA recurrence 1, 3
• Schedule follow-up appointment 1