From the Guidelines
The management of Diabetic Ketoacidosis (DKA) should prioritize fluid resuscitation, insulin therapy, and electrolyte replacement, with a focus on individualized treatment based on careful clinical and laboratory assessment, as outlined in the 2024 ADA guidelines 1.
Subjective
- Symptoms such as polyuria, polydipsia, nausea, vomiting, abdominal pain, and altered mental status should be assessed
- Patient history, including medication adherence and potential precipitating factors like infection, should be considered
Objective
- Vital signs, particularly those indicating dehydration, should be documented
- Physical exam findings, including signs of dehydration and potential sources of infection, should be noted
- Laboratory values, including blood glucose, arterial pH, serum bicarbonate, and serum/urine ketones, should be evaluated to confirm DKA diagnosis
Assessment
- DKA diagnosis should be confirmed based on blood glucose >250 mg/dL, arterial pH <7.30, serum bicarbonate <18 mEq/L, and positive serum/urine ketones
- Precipitating factors, such as infection or medication non-adherence, should be identified
Plan
- Fluid resuscitation with 0.9% sodium chloride at 15-20 mL/kg/hr initially, followed by 0.45% sodium chloride at 4-14 mL/kg/hr if sodium is normal or elevated, is recommended 1
- Insulin therapy should begin with IV regular insulin as a 0.1 units/kg bolus, followed by continuous infusion at 0.1 units/kg/hr, titrating to achieve glucose reduction of 50-75 mg/dL/hr
- Potassium replacement is indicated when levels fall below 5.2 mEq/L
- Bicarbonate therapy is generally not recommended, except in cases of severe acidosis (pH <6.9) 1
- Transition to subcutaneous insulin should occur when ketoacidosis resolves, with overlap between IV insulin discontinuation and subcutaneous insulin administration, and consideration of basal insulin analog administration to prevent rebound hyperglycemia 1
From the Research
SOAP Outline for DKA based on 2024 ADA Guidelines
Subjective
- Patient presents with symptoms of DKA, including hyperglycemia, metabolic acidosis, and ketosis 2, 3
- Patient may have a history of diabetes mellitus, with DKA more commonly occurring in those with type 1 diabetes, but also occurring in those with type 2 diabetes 2
- Patient may have experienced a precipitating event, such as infection, new diagnosis of diabetes, or nonadherence to insulin therapy 2, 3
Objective
- Laboratory results show elevated blood glucose levels, high urinary or blood ketoacids, and a high anion gap metabolic acidosis 3
- Patient's pH level is <7.3, bicarbonate level is <18, and anion gap is >12 4
- Patient may have signs of dehydration, such as dry mouth, decreased urine output, and decreased blood pressure 5
Assessment
- Diagnosis of DKA is confirmed based on laboratory results and clinical presentation 3
- Patient is at risk for complications, such as cerebral edema, cardiac arrhythmias, and respiratory depression 2, 3
- Patient requires aggressive treatment, including intravenous fluids, insulin therapy, and electrolyte replacement 2, 3, 5
Plan
- Administer intravenous fluids, such as isotonic normal saline or lactated Ringers, to restore circulating volume and correct dehydration 4, 5
- Initiate insulin therapy, using a continuous intravenous infusion of regular human insulin, with an initial dose of 0.1 UI/kg/h 5, 6
- Replace electrolytes, including potassium, phosphate, and bicarbonate, as needed 5
- Monitor patient's clinical and laboratory status closely, including pH, bicarbonate, and anion gap levels, as well as blood glucose and ketone levels 3, 5
- Identify and treat any underlying precipitating event, such as infection or nonadherence to insulin therapy 2, 3
- Develop a discharge plan, including education on insulin therapy, self-care, and prevention of future episodes of DKA 2