Management of Diabetic Ketoacidosis (DKA) in the ICU

Initial Assessment and Stabilization

• The American Diabetes Association recommends performing careful clinical and laboratory assessment including plasma glucose, blood urea nitrogen, creatinine, serum ketones, electrolytes with calculated anion gap, osmolality, urinalysis, arterial blood gases, and complete blood count in patients with DKA 1, 2
• Identifying and treating any underlying cause of DKA, such as sepsis, myocardial infarction, or stroke, is crucial for effective management, as recommended by the American Diabetes Association 1, 3
• Management goals for DKA include restoration of circulatory volume, tissue perfusion, resolution of hyperglycemia/ketoacidosis, and correction of electrolyte imbalances, with a strength of evidence level of high, according to the American Diabetes Association 1, 2

Fluid Resuscitation

• The American Diabetes Association recommends beginning with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour during the first hour to restore circulatory volume and tissue perfusion in patients with DKA, with a moderate level of evidence 1, 2
• Continuing fluid replacement based on hemodynamic status, serum electrolyte levels, and urine output is essential for effective management, as recommended by the American Diabetes Association 1, 2
• Monitoring fluid input/output and clinical examination to assess progress with fluid replacement is crucial, with a high level of evidence, according to the American Diabetes Association 1, 2

Insulin Therapy

• The American Diabetes Association recommends continuous intravenous insulin as the standard of care for critically ill and mentally obtunded patients with DKA, with a high level of evidence 1, 3, 2
• For mild or moderate uncomplicated DKA, subcutaneous rapid-acting insulin analogs may be used when combined with aggressive fluid management, as recommended by the American Diabetes Association, with a moderate level of evidence 1, 3
• Monitoring blood glucose every 2-4 hours while the patient takes nothing by mouth and adjusting insulin dosing accordingly is essential, with a high level of evidence, according to the American Diabetes Association 1, 2

Electrolyte Management

• The American Diabetes Association recommends monitoring potassium levels closely as total body potassium deficits are common despite potentially normal or elevated initial serum levels due to acidosis, with a high level of evidence 1, 2
• Adding 20-40 mEq/L potassium to the infusion when serum levels fall below 5.5 mEq/L is recommended, as per the American Diabetes Association, with a moderate level of evidence 1, 2
• Monitoring and replacing other electrolytes, including phosphate, magnesium, and calcium, as needed, is crucial, with a high level of evidence, according to the American Diabetes Association 1, 2
• Bicarbonate administration is generally not recommended, as studies have shown it makes no difference in resolution of acidosis or time to discharge, with a high level of evidence, according to the American Diabetes Association 1, 3, 2

Monitoring for Resolution

• The American Diabetes Association recommends drawing blood every 2-4 hours to determine serum electrolytes, glucose, blood urea nitrogen, creatinine, and osmolality during therapy, with a high level of evidence 1, 2
• Treatment success is indicated by resolution of acidosis (pH >7.3), serum bicarbonate ≥18 mEq/L, anion gap ≤12 mEq/L, and improvement in clinical symptoms, as defined by the American Diabetes Association, with a high level of evidence 1, 2

Transition from ICU and Discharge Planning

• The American Diabetes Association recommends a structured discharge plan tailored to the individual patient to reduce length of hospital stay and readmission rates, with a moderate level of evidence 1, 3, 2
• Discharge planning should begin at admission and be updated as patient needs change, as recommended by the American Diabetes Association, with a moderate level of evidence 1, 3
• Scheduling follow-up appointments prior to discharge can increase the likelihood that patients will attend, with a low level of evidence, according to the American Diabetes Association 3, 2

Common Pitfalls and Caveats

• Inadequate fluid resuscitation can delay recovery and worsen outcomes, with a high level of evidence, according to the American Diabetes Association 1, 2
• Premature discontinuation of insulin therapy before complete resolution of ketosis can lead to recurrence of DKA, with a high level of evidence, as recommended by the American Diabetes Association 1, 2
• Failure to monitor and replace electrolytes can lead to complications, particularly cardiac arrhythmias, with a high level of evidence, according to the American Diabetes Association 1, 2
• Not identifying or treating the underlying cause of DKA can lead to treatment failure, with a high level of evidence, as recommended by the American Diabetes Association 1, 3

Management of Diabetic Ketoacidosis

Initial Assessment and Management

• The American Diabetes Association recommends insulin therapy be initiated immediately for children and adolescents with type 2 diabetes who are ketotic or in diabetic ketoacidosis 4

Fluid Resuscitation and Insulin Therapy

• The American College of Endocrinology and the American Diabetes Association recommend management goals including restoration of circulatory volume and tissue perfusion, resolution of hyperglycemia/ketoacidosis, and correction of electrolyte imbalances 5, 6
• For mild or moderate uncomplicated diabetic ketoacidosis, subcutaneous rapid-acting insulin analogs may be used when combined with aggressive fluid management, as recommended by the American Diabetes Association 5, 6

Electrolyte Management

• The Endocrine Society notes that hypokalaemia is common (about 50%) during treatment of hyperglycaemic crises, and severe hypokalaemia (<2.5 mEq/L) is associated with increased inpatient mortality 7, 8
• Bicarbonate administration is generally not recommended by the American Diabetes Association, as studies have shown it makes no difference in resolution of acidosis or time to discharge 5, 6

Monitoring for Resolution and Special Considerations

• Successful transition from intravenous to subcutaneous insulin requires administration of basal insulin 2–4 h prior to the intravenous insulin being stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia, as recommended by the American Diabetes Association 5, 6
• The American Heart Association and the American Diabetes Association suggest that for patients with ischaemic events (myocardial infarction or ischaemic stroke), rapid control of glucose values might be warranted due to the known potential harms associated with hyperglycemia 7, 8

Transitioning from IV to Subcutaneous Insulin

• Factors to consider when transitioning patients from continuous insulin infusion to subcutaneous insulin include stable glucose measurements for at least 4–6 h consecutively, normal anion gap and resolution of acidosis in diabetic ketoacidosis, as recommended by The Lancet Diabetes and Endocrinology 7, 8
• Recent studies reported by the American Diabetes Association have shown that the administration of a low dose of basal insulin analog in addition to intravenous insulin infusion may prevent rebound hyperglycemia without increased risk of hypoglycemia 5

Discharge Planning and Prevention

• The American Diabetes Association recommends providing structured discharge communication including information on medication changes, pending tests, and follow-up needs 5
• The American Diabetes Association suggests educating patients on diabetes management, self-monitoring of blood glucose, home blood glucose goals, and when to call their provider 6
• The American Association of Diabetes Educators recommends providing education on recognition, treatment, and prevention of hyperglycemia and hypoglycemia 6
• The American Diabetes Association recommends ensuring patients have appropriate medications, supplies, and prescriptions at discharge to avoid dangerous gaps in care 6