Treatment of Diabetic Ketoacidosis in Type 2 Diabetes

Initial Assessment and Stabilization

The American Diabetes Association recommends diagnostic confirmation of DKA, which requires blood glucose >250 mg/dL, arterial pH <7.3, serum bicarbonate <15 mEq/L, and presence of ketonemia or ketonuria 1
Essential laboratory evaluation includes plasma glucose, blood urea nitrogen/creatinine, serum ketones, electrolytes with calculated anion gap, osmolality, urinalysis, urine ketones, arterial blood gases, complete blood count with differential, and electrocardiogram 1
Identify precipitating factors, such as infection, cerebrovascular accident, alcohol abuse, pancreatitis, myocardial infarction, trauma, drugs (particularly SGLT2 inhibitors), or insulin discontinuation/inadequacy 1

Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour (approximately 1-1.5 L in the average adult) during the first hour 1
When serum glucose reaches 250 mg/dL, change fluid to 5% dextrose with 0.45-0.75% NaCl to prevent hypoglycemia while continuing insulin therapy 1
Total fluid replacement should aim to correct estimated deficits within 24 hours 1

For critically ill and mentally obtunded patients with DKA, continuous intravenous insulin is the standard of care, starting with 0.1 units/kg/hour 2, 1
If plasma glucose does not fall by 50 mg/dL from initial value in the first hour, check hydration status; if acceptable, double the insulin infusion rate every hour until a steady glucose decline of 50-75 mg/h is achieved 1
Continue insulin infusion until complete resolution of ketoacidosis (pH >7.3, serum bicarbonate ≥18 mEq/L, and anion gap ≤12 mEq/L) regardless of glucose levels 1

Potassium replacement is critical, despite potentially normal or elevated initial serum levels due to acidosis, total body potassium depletion is universal in DKA 1, 3
If K+ <3.3 mEq/L, delay insulin therapy and aggressively replace potassium until levels reach ≥3.3 mEq/L to prevent life-threatening arrhythmias and respiratory muscle weakness 1
Target serum potassium of 4-5 mEq/L throughout treatment 1

Draw blood every 2-4 hours to determine serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH 1, 3
Direct measurement of β-hydroxybutyrate in blood is the preferred method for monitoring DKA 1
Target glucose between 150-200 mg/dL until DKA resolution parameters are met 1

DKA is resolved when ALL of the following are met: glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L 1

Once DKA is resolved, administer basal insulin (intermediate or long-acting) 2-4 hours BEFORE stopping IV insulin infusion to prevent recurrence of ketoacidosis and rebound hyperglycemia 1
Many patients with type 2 diabetes can eventually be weaned from insulin therapy and subsequently managed with metformin and lifestyle modification 4, 5

Before discharge, ensure identification of the health care provider who will provide diabetes care after discharge, patient understanding of diabetes diagnosis, self-monitoring of blood glucose, home blood glucose goals, and when to call the provider 2
Education on recognition, treatment, and prevention of hyperglycemia and hypoglycemia is essential 2
Discharge summaries should be transmitted to the primary care provider as soon as possible after discharge 2