From the Guidelines
The initial treatment for Diabetic Ketoacidosis (DKA) should be fluids, as the primary goal is to restore circulatory volume and tissue perfusion, with insulin therapy initiated thereafter 1.
Key Considerations
- The management of DKA requires individualization of treatment based on a careful clinical and laboratory assessment, with goals including restoration of circulatory volume, resolution of hyperglycemia, and correction of electrolyte imbalance and acidosis 1.
- Aggressive fluid management is crucial in the treatment of DKA, with the aim of correcting estimated deficits within the first 24 hours 1.
- Insulin therapy, typically with continuous intravenous insulin, is the standard of care for critically ill and mentally obtunded individuals with DKA, while subcutaneous rapid-acting analogs may be used for mild or moderate DKA in combination with aggressive fluid management 1.
- Basal insulin should be administered 2-4 hours before stopping intravenous insulin to prevent recurrence of ketoacidosis and rebound hyperglycemia 1.
- The use of bicarbonate in patients with DKA is generally not recommended, as it has been shown to make no difference in the resolution of acidosis or time to discharge 1.
Treatment Approach
- Initial fluid therapy should be directed toward expansion of the intravascular and extravascular volume, with isotonic saline (0.9% NaCl) at a rate of 10-20 ml/kg/h in the first hour, followed by continued fluid therapy to replace the fluid deficit evenly over 48 hours 1.
- Insulin therapy should be initiated with a low dose of regular insulin, typically 0.1 U/kg/h, and adjusted as needed to achieve a glucose reduction of 50-75 mg/dl/h 1.
The FDA Drug Labels for insulin (IV) do not address this question.
From the Research
Initial Treatment for Diabetic Ketoacidosis (DKA)
The initial treatment for DKA involves:
- Administering intravenous fluids to restore intravascular, interstitial, and intracellular compartments 2, 3, 4, 5
- Using isotonic normal saline as the standard for initial fluid resuscitation, although balanced solutions have been shown to have faster DKA resolution 2
- Starting continuous IV insulin for DKA management after fluid status has been restored and potassium levels have been achieved 2
Role of Insulin in DKA Treatment
- Insulin is a mainstay of treatment in DKA, but controversy remains over the optimal dose and administration 6
- An initial bolus dose of insulin prior to a continuous infusion is not recommended due to the potential for complications such as hypokalemia 6
- Continuous IV insulin is recommended for DKA management, with subcutaneous insulin started only after the resolution of metabolic acidosis 2
Key Considerations in DKA Treatment
- Monitoring glucose and electrolyte levels closely to prevent complications arising from treatment 2, 4, 5
- Avoiding hyperglycemia overcorrection to prevent cerebral edema (CE) 2, 3, 4
- Using balanced IV fluid solutions to restore volume status, followed by continuous IV insulin and electrolyte replacement 2