What are the initial workup and management for Diabetic Ketoacidosis (DKA)?

From the Guidelines

The initial workup for diabetic ketoacidosis (DKA) should include a comprehensive assessment of the patient's condition through laboratory tests and physical examination, with management prioritizing restoration of circulatory volume, resolution of ketoacidosis, and correction of electrolyte imbalance and acidosis, as outlined in the most recent guidelines 1.

Initial Assessment and Management

The initial assessment should include serum glucose, electrolytes, blood urea nitrogen, creatinine, complete blood count, urinalysis for ketones, arterial blood gas, and serum ketones. Calculate the anion gap to confirm DKA diagnosis.

• Management goals include restoration of circulatory volume and tissue perfusion, resolution of ketoacidosis, and correction of electrolyte imbalance and acidosis.
• It is also essential to treat any correctable underlying cause of DKA, such as sepsis, myocardial infarction, or stroke.
• In critically ill and mentally obtunded individuals with DKA or HHS, continuous intravenous insulin is the standard of care, as per the latest recommendations 1.

Fluid Resuscitation and Insulin Therapy

• Aggressive fluid resuscitation using isotonic saline at 15-20 mL/kg/hr for the first hour, then 4-14 mL/kg/hr based on hemodynamic status, is crucial.
• Regular insulin should be administered as an IV bolus of 0.1 units/kg followed by a continuous infusion at 0.1 units/kg/hr, with adjustments based on hourly glucose monitoring.
• When glucose reaches 200-250 mg/dL, add dextrose to IV fluids while continuing insulin to clear ketosis.

Electrolyte Replacement and Monitoring

• Potassium replacement is crucial, with 20-30 mEq/L added to IV fluids when serum potassium is <5.3 mEq/L and urine output is adequate.
• Bicarbonate therapy is generally reserved for severe acidosis (pH <6.9), as its use is not recommended unless absolutely necessary, according to recent studies 1.
• Throughout treatment, monitor vital signs, mental status, fluid balance, and electrolytes every 2-4 hours.

Underlying Cause Identification and Treatment

• The underlying cause of DKA must be identified and treated, which commonly includes infection, medication non-adherence, or new-onset diabetes.
• This approach addresses both the acute metabolic derangements and prevents complications like cerebral edema, which can occur with overly rapid correction, emphasizing the importance of careful management based on the latest evidence 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. Eating significantly more than your meal plan suggests. Developing a fever, infection, or other significant stressful situation. 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.

The initial workup for Diabetic Ketoacidosis (DKA) includes:

• Blood tests to check glucose and ketone levels
• Urine tests to check for ketones The management of DKA involves:
• Insulin therapy to lower blood glucose levels
• Fluid replacement to treat dehydration
• Electrolyte replacement to treat electrolyte imbalances
• Monitoring of blood glucose, ketone, and electrolyte levels It is essential to obtain medical assistance immediately if symptoms of DKA occur 2.

From the Research

Initial Workup for DKA

• The initial workup for diabetic ketoacidosis (DKA) includes obtaining a thorough but rapid history and performing a physical examination to identify possible precipitating factors 3.
• Laboratory tests such as pH, bicarbonate, and anion gap are used to diagnose DKA 3, 4.

Management of DKA

• The major treatment of DKA includes initial rehydration with subsequent potassium replacement and low-dose insulin therapy 3.
• Fluid resuscitation is a cornerstone of DKA management, with traditional guidelines recommending isotonic normal saline (NS) for initial volume replacement 5, 3.
• However, recent studies suggest that large volumes of NS may lead to undesirable outcomes such as hyperchloremic metabolic acidosis 5, 6, 7.
• Balanced crystalloids, such as lactated Ringers, may be a better choice for initial resuscitation in DKA patients, as they may reduce the risk of complications related to hyperchloremia and improve clinical outcomes 5, 6, 7.
• The use of bicarbonate is not recommended in most patients 3.

Fluid Resuscitation

• A systematic review and meta-analysis found that fluid resuscitation with balanced electrolyte solutions results in faster resolution of DKA than with 0.9% saline in adults 7.
• Another study found that large-volume resuscitation with isotonic NS in DKA patients is associated with increased ICU length of stay, prolonged insulin infusion, and a higher incidence of non-anion gap metabolic acidosis 5.
• A systematic review of clinical trials found that balanced solutions were generally associated with faster correction of pH, and the time to reach overall DKA endpoints was comparable in both groups 6.

Monitoring and Prevention

• Continuous follow-up of patients using treatment algorithms and flow sheets can help to minimize adverse outcomes 3.
• Preventive measures include patient education and instructions for the patient to contact the physician early during an illness 3, 4.
• Discharge plans should include appropriate choice and dosing of insulin regimens and interventions to prevent recurrence of DKA 4.