What is the recommended management protocol for diabetic ketoacidosis according to the latest guidelines?

DKA Management: Updated Guidelines

Begin immediate fluid resuscitation with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour during the first hour, followed by continuous IV regular insulin at 0.1 units/kg/hour once serum potassium is ≥3.3 mEq/L, and add dextrose to fluids when glucose falls to 250 mg/dL while continuing insulin until complete resolution of ketoacidosis. 1, 2, 3

Diagnostic Criteria

Confirm DKA with all of the following:

• Blood glucose >250 mg/dL 1, 2
• Arterial pH <7.3 (or venous pH, which runs ~0.03 units lower) 1, 2
• Serum bicarbonate <15 mEq/L 1, 2
• Anion gap >10-12 mEq/L 1, 2
• Moderate-to-large ketonemia or ketonuria 1, 2

Critical point: Euglycemic DKA (glucose <200-250 mg/dL with ketoacidosis) is increasingly recognized, especially with SGLT2 inhibitor use—measure β-hydroxybutyrate directly in blood, not urine ketones. 1

Initial Laboratory Workup

Obtain immediately: 1, 2, 3

• Plasma glucose, venous or arterial blood gas
• Complete metabolic panel with calculated anion gap
• β-hydroxybutyrate (preferred over nitroprusside-based ketone tests) 1, 2
• BUN, creatinine, serum osmolality
• Urinalysis, CBC with differential
• ECG (to detect hyperkalemia changes and ischemia) 1, 3
• Blood, urine, and throat cultures if infection suspected 1, 2, 3

Fluid Resuscitation Protocol

First Hour

Administer isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour (~1-1.5 L in average adult) to restore intravascular volume and renal perfusion. 1, 2, 3 Some newer evidence supports balanced electrolyte solutions as an alternative. 3

After First Hour

Calculate corrected sodium: add 1.6 mEq/L for each 100 mg/dL glucose above 100 mg/dL. 1, 2

• If corrected sodium is normal or elevated: Switch to 0.45% NaCl at 4-14 mL/kg/hour 1, 2
• If corrected sodium is low: Continue 0.9% NaCl at 4-14 mL/kg/hour 1, 2

Total fluid deficit is typically 6-9 L; replace over 24 hours while limiting osmolality change to ≤3 mOsm/kg/hour to prevent cerebral edema. 1, 2

When Glucose Reaches 250 mg/dL

Switch to 5% dextrose with 0.45-0.75% NaCl while maintaining insulin infusion. 1, 2, 3 This prevents hypoglycemia and allows insulin to continue clearing ketones. 1

Potassium Management (Critical)

Total body potassium depletion is universal in DKA (~3-5 mEq/kg) even if serum levels appear normal or elevated initially. 1, 2 Insulin drives potassium intracellularly, causing rapid decline. 1

Algorithm based on serum potassium:

• K⁺ <3.3 mEq/L: HOLD insulin and replace potassium aggressively at 20-40 mEq/hour until K⁺ ≥3.3 mEq/L to prevent fatal arrhythmias, cardiac arrest, and respiratory muscle weakness 1, 2, 3
• K⁺ 3.3-5.5 mEq/L: Add 20-30 mEq/L potassium to IV fluids (2/3 KCl + 1/3 KPO₄) once adequate urine output confirmed 1, 2, 3
• K⁺ >5.5 mEq/L: Withhold potassium initially but monitor every 2-4 hours as levels will fall rapidly with insulin 1, 2

Target serum potassium: 4-5 mEq/L throughout treatment. 1, 2

Insulin Therapy

Standard IV Protocol (Moderate-Severe or Critically Ill DKA)

1. Confirm serum potassium ≥3.3 mEq/L before starting insulin 1, 2
2. Optional IV bolus: 0.1-0.15 units/kg regular insulin 1, 2
3. Continuous IV infusion: 0.1 units/kg/hour regular insulin 1, 2, 3
4. Target glucose decline: 50-75 mg/dL per hour 1, 2
5. If glucose does not fall ≥50 mg/dL in first hour despite adequate hydration: Double insulin rate hourly until steady decline achieved 1, 2, 3

Do NOT stop insulin when glucose reaches 250 mg/dL—add dextrose to fluids and continue insulin until ketoacidosis resolves. 1, 2 Premature insulin cessation is a common cause of recurrent DKA. 1

Alternative for Mild-Moderate Uncomplicated DKA

For hemodynamically stable, alert patients with mild-moderate DKA: Subcutaneous rapid-acting insulin analogs (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, 3 However, continuous IV insulin remains standard for critically ill or mentally obtunded patients. 1, 3

Bicarbonate: Generally NOT Recommended

Do NOT administer bicarbonate for pH >6.9-7.0. 1, 2, 3 Multiple studies show no benefit in acidosis resolution time or hospital length of stay, and bicarbonate may worsen ketosis, cause hypokalemia, and increase cerebral edema risk. 1, 3

Consider bicarbonate only if pH <6.9: Give 100 mmol sodium bicarbonate in 400 mL sterile water at 200 mL/hour. 2, 3

Monitoring During Treatment

Draw blood every 2-4 hours for: 1, 2, 3

• Serum electrolytes (Na⁺, K⁺, Cl⁻)
• Glucose
• BUN, creatinine
• Calculated osmolality
• Venous pH (arterial gases generally unnecessary after initial diagnosis) 1, 2
• β-hydroxybutyrate (preferred over nitroprusside-based tests) 1, 2

Nitroprusside-based ketone tests miss β-hydroxybutyrate (the predominant ketone body) and may falsely suggest worsening ketosis during treatment—avoid them. 1, 2

Resolution Criteria

DKA is resolved when ALL of the following are met: 1, 2, 3

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

Ketonemia resolves more slowly than hyperglycemia—do not stop insulin prematurely. 1

Transition to Subcutaneous Insulin

Administer basal subcutaneous insulin (NPH, detemir, glargine, or degludec) 2-4 hours BEFORE stopping IV insulin infusion to prevent rebound hyperglycemia and recurrent ketoacidosis. 1, 2, 3 This overlap period is essential. 1

Once patient can eat: Start multiple-dose regimen combining short/rapid-acting with intermediate/long-acting insulin (~0.5-1.0 units/kg/day for newly diagnosed patients). 1, 2

If patient remains NPO after resolution: Continue IV fluids and supplement with subcutaneous regular insulin every 4 hours (5-unit increments for each 50 mg/dL glucose above 150 mg/dL, up to 20 units for glucose ~300 mg/dL). 1, 2

Identify and Treat Precipitating Causes

Common triggers to actively search for: 1, 2, 3

• Infection (most common): Obtain cultures and start appropriate antibiotics promptly 1, 2, 3
• Myocardial infarction (may be masked by DKA) 1, 3
• Cerebrovascular accident 1, 3
• Insulin omission or inadequacy 1, 3
• SGLT2 inhibitor use (causes euglycemic DKA): Discontinue immediately and do not restart until 3-4 days after metabolic stability 1, 3
• Pancreatitis, trauma, glucocorticoid therapy, pregnancy 1, 3

Critical Pitfalls to Avoid

1. Starting insulin before correcting severe hypokalemia (K⁺ <3.3 mEq/L) causes life-threatening arrhythmias 1, 2
2. Stopping insulin when glucose falls to 250 mg/dL without adding dextrose leads to recurrent ketoacidosis 1, 2
3. Inadequate potassium monitoring and replacement is a leading cause of DKA mortality 1
4. Overly rapid correction of osmolality (>3 mOsm/kg/hour) increases cerebral edema risk 1, 2
5. Using nitroprusside-based ketone tests misses β-hydroxybutyrate and delays appropriate therapy 1, 2
6. Stopping IV insulin without prior basal subcutaneous insulin causes rebound hyperglycemia 1, 3
7. Routine bicarbonate use provides no benefit and may cause harm 1, 3

Special Populations

Pediatric Considerations

Cerebral edema is more common in children and is the leading cause of DKA mortality in this population. 4, 5 Risk factors include severe acidosis, greater hypocapnia, higher BUN at presentation, and bicarbonate treatment. 4 Initial isotonic fluid resuscitation is now recommended for all pediatric patients, followed by repletion over 36-48 hours. 5

SGLT2 Inhibitor-Associated Euglycemic DKA

SGLT2 inhibitors are the leading contemporary cause of euglycemic DKA. 1 Discontinue immediately when DKA suspected and do not restart until 3-4 days after metabolic stability. 1, 3 Check ketones during any illness even if glucose is normal. 1

Discharge Planning

Before discharge ensure: 1, 3

• Identified outpatient diabetes care provider
• Education on DKA recognition, prevention, and management
• Understanding of glucose monitoring and insulin administration
• Recognition and treatment of hyperglycemia/hypoglycemia
• Appropriate insulin regimen prescribed with verified medication access
• Follow-up appointment scheduled