Management of Diabetic Ketoacidosis

Initial Assessment and Diagnosis

The American Diabetes Association recommends assessing for DKA diagnostic criteria: blood glucose >250 mg/dL, arterial pH <7.3, bicarbonate <15 mEq/L, and moderate ketonemia or ketonuria 1
Direct measurement of β-hydroxybutyrate in blood is preferred over urine ketones for monitoring DKA 1
Evaluate for precipitating factors such as infection, medication non-adherence, or new-onset diabetes, with the American Diabetes Association suggesting that infection is a common precipitant 1, 2
The combination of vomiting illness accompanied by ketosis strongly suggests DKA, which requires immediate medical attention, according to the American Diabetes Association 3, 4

The American Diabetes Association recommends beginning with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hr to restore circulatory volume and tissue perfusion 1
After the first hour, continue fluid replacement based on hemodynamic status, typically at 4-14 mL/kg/hr, as suggested by the American Diabetes Association 1
Adequate fluid intake must be assured as dehydration is more likely to necessitate hospitalization in patients with diabetes, according to the American Diabetes Association 3

Start continuous intravenous regular insulin at 0.1 units/kg/hr after fluid resuscitation has begun, as recommended by the American Diabetes Association 1
If glucose does not fall by 50-75 mg/dL in the first hour, double the insulin infusion rate, according to the American Diabetes Association 1
Once blood glucose reaches 200-250 mg/dL, add dextrose to IV fluids while continuing insulin infusion to prevent hypoglycemia, as suggested by the American Diabetes Association 1

Monitor serum potassium levels every 2-4 hours as insulin therapy can cause hypokalemia, according to the American Diabetes Association 1
Begin potassium replacement when serum levels fall below 5.2 mEq/L, provided the patient has adequate urine output, as recommended by the American Diabetes Association 1
Typical potassium replacement is 20-30 mEq per liter of IV fluid, according to the American Diabetes Association 1

Check blood glucose every 1-2 hours until stable, as recommended by the American Diabetes Association 1
Monitor electrolytes, blood urea nitrogen, creatinine, and venous pH every 2-4 hours, according to the American Diabetes Association 1
Assess for signs of cerebral edema, particularly in children and adolescents, such as headache, altered mental status, seizures, and bradycardia, as suggested by the American Diabetes Association 1, 2

Identify and treat underlying causes such as infection or medication non-compliance, according to the American Diabetes Association 1, 3, 4
Aggressive glycemic management with insulin may reduce morbidity in patients with severe acute illness, as suggested by the American Diabetes Association 3, 4

Once DKA has resolved, transition to subcutaneous insulin, as recommended by the American Diabetes Association 1
Administer subcutaneous basal insulin 2-4 hours before discontinuing IV insulin to prevent recurrence of ketoacidosis, according to the American Diabetes Association 1, 5

Review sick-day management with patients, including when to contact healthcare providers, blood glucose goals, and use of supplemental short-acting insulin during illness, as recommended by the American Diabetes Association 6
Advise patients never to discontinue insulin during illness and to seek professional advice early, according to the American Diabetes Association 6
Educate patients on monitoring blood glucose, urine ketones when blood glucose is >300 mg/dL, and recording insulin administered, as suggested by the American Diabetes Association 6

Be aware of euglycemic diabetic ketoacidosis risk in patients taking SGLT2 inhibitors, which requires the same urgent management despite potentially lower blood glucose levels, according to the American College of Cardiology 7
Patients should be advised to seek immediate care if they develop symptoms potentially associated with diabetic ketoacidosis, such as nausea, vomiting, abdominal pain, and generalized weakness, as recommended by the American College of Cardiology 7