Management of Diabetic Ketoacidosis (DKA)

Initial Assessment and Diagnosis

The American Diabetes Association recommends performing laboratory evaluation including plasma glucose, blood urea nitrogen/creatinine, serum ketones, electrolytes with calculated anion gap, osmolality, urinalysis, urine ketones, arterial blood gases, complete blood count, and electrocardiogram for patients with suspected DKA 1, 2
Diagnostic criteria for DKA include plasma glucose >250 mg/dl, arterial pH <7.30, serum bicarbonate <18 mEq/l, and positive serum and urine ketones, as recommended by the American Diabetes Association 1
Obtain bacterial cultures (urine, blood, throat) if infection is suspected and administer appropriate antibiotics, as suggested by the American Diabetes Association 1

The American Diabetes Association recommends beginning with isotonic saline (0.9% NaCl) at a rate of 15-20 ml/kg body weight/hour during the first hour to restore intravascular volume and renal perfusion 1, 2
Subsequent fluid choice depends on hydration status, serum electrolyte levels, and urine output, according to the American Diabetes Association 1
Total fluid replacement should be approximately 1.5 times the 24-hour maintenance requirements, as suggested by the American Diabetes Association 2

The American Diabetes Association recommends starting continuous intravenous regular insulin infusion at 0.1 units/kg/hour without an initial bolus for moderate to severe DKA 3, 2
If plasma glucose does not fall by 50 mg/dl in the first hour, double the insulin infusion rate hourly until a steady glucose decline between 50-75 mg/hour is achieved, as recommended by the American Diabetes Association 3
When serum glucose reaches 250 mg/dl, decrease insulin infusion to 0.05-0.1 units/kg/hour and add dextrose to IV fluids to prevent hypoglycemia while continuing insulin to clear ketosis, according to the American Diabetes Association 3, 4

The American Diabetes Association recommends monitoring potassium levels closely as insulin therapy and correction of acidosis can cause hypokalemia 1, 3
Include 20-30 mEq/L potassium in IV fluids once renal function is assured and serum potassium is <5.3 mEq/L, as suggested by the American Diabetes Association 2
Maintain serum potassium between 4-5 mmol/L throughout treatment, according to the American Diabetes Association 4

The American Diabetes Association recommends checking blood glucose every 1-2 hours 3
Draw blood every 2-4 hours to determine serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH, as recommended by the American Diabetes Association 3, 4
Follow venous pH (typically 0.03 units lower than arterial pH) and anion gap to monitor resolution of acidosis, according to the American Diabetes Association 4

The American Diabetes Association recommends that bicarbonate administration is generally not recommended for DKA patients with pH >6.9 3, 4

When DKA resolves (glucose <200 mg/dl, serum bicarbonate ≥18 mEq/l, venous pH >7.3, and anion gap ≤12 mEq/L), transition to subcutaneous insulin, as recommended by the American Diabetes Association 3, 4
Administer basal insulin 2-4 hours before stopping the IV insulin infusion to prevent recurrence of ketoacidosis, according to the American Diabetes Association 4, 2

Premature termination of insulin therapy before complete resolution of ketosis can lead to recurrence of DKA, as warned by the American Diabetes Association 3, 4
Inadequate monitoring of potassium levels during insulin therapy can cause dangerous hypokalemia, according to the American Diabetes Association 3
Interruption of insulin infusion when glucose levels fall without adding dextrose is a common cause of persistent or worsening ketoacidosis, as noted by the American Diabetes Association 4
Relying on nitroprusside method to measure ketones is misleading as it only measures acetoacetic acid and acetone, not β-hydroxybutyrate, as pointed out by the American Diabetes Association 3

The American Diabetes Association recommends targeting a glucose decline of 50-75 mg/dl/hour, and if plasma glucose does not fall by 50 mg/dl in the first hour, verify adequate hydration, then double the insulin infusion rate hourly until achieving steady glucose decline of 50-75 mg/hour, according to the Diabetes Care guideline 5
The American Diabetes Association suggests continuing insulin infusion until complete resolution of ketoacidosis, regardless of glucose levels, with resolution requiring a venous pH >7.3, serum bicarbonate ≥18 mEq/L, anion gap ≤12 mEq/L, and glucose <200 mg/dl, as recommended by the Diabetes Care guideline 5

The American Diabetes Association recommends routine phosphate replacement has not shown clinical benefit, but careful phosphate replacement may be indicated in patients with cardiac dysfunction, anemia, or respiratory depression, or serum phosphate <1.0 mg/dl, according to the Diabetes Care guideline 5

The American Diabetes Association suggests drawing blood every 2-4 hours for serum electrolytes, glucose, BUN, creatinine, osmolality, and venous pH, and following venous pH and anion gap to monitor acidosis resolution, as recommended by the Diabetes Care guideline 5
The American Diabetes Association recommends direct measurement of β-hydroxybutyrate in blood as the preferred method for ketone monitoring, as stated in the Diabetes Care guideline 5

The American Diabetes Association suggests using gradual correction of glucose and osmolality to minimize the risk of cerebral edema, according to the Diabetes Care guideline 5