Stepwise Management of Diabetic Ketoacidosis
DKA should be treated with rapid fluid resuscitation, intravenous insulin infusion, electrolyte replacement, and correction of precipitating factors. The Joint British Diabetes Society‑Inpatient (JBDS‑IP) guideline recommends a fixed‑rate intravenous insulin infusion (FRIII) of 0.05 units/kg/h once plasma glucose falls below 14 mmol/L to reduce complications [1]. Early recognition and treatment are emphasized in a clinical resource on DKA [2].
Fluid Resuscitation Protocol
- Initiate isotonic saline (0.9 % NaCl) at 15–20 mL/kg in the first hour (≈1–1.5 L for most adults) [2].
- Switch to 0.45 % NaCl if corrected serum sodium > 145 mmol/L or if glucose remains > 250 mg/dL after the initial bolus [2].
- Add 5 % dextrose when plasma glucose reaches 200–250 mg/dL to prevent hypoglycemia while ketosis persists [2].
Insulin Therapy Algorithm
- Begin continuous IV regular insulin at 0.1 units/kg/h after the initial fluid bolus [2].
- Reduce the infusion to 0.05 units/kg/h when plasma glucose falls < 14 mmol/L, as per JBDS‑IP recommendation [1].
- Continue insulin infusion until serum bicarbonate ≥ 18 mmol/L, pH > 7.3, and the anion gap normalizes [2].
Electrolyte Management
- Monitor serum potassium hourly.
- Administer 20–30 mmol KCl per liter of IV fluid if serum potassium is 3.3–5.0 mmol/L; hold insulin if potassium < 3.3 mmol/L and replete potassium before insulin initiation [2].
- Replace phosphate only if serum phosphate < 0.5 mmol/L or if symptomatic [2].
Monitoring and Laboratory Targets
- Check glucose, electrolytes, venous pH, bicarbonate, and anion gap every 1–2 hours until stable [2].
- Target glucose 150–200 mg/dL after initial reduction, then 100–150 mg/dL until ketosis resolves [2].
- Aim for serum bicarbonate ≥ 18 mmol/L and venous pH > 7.3 before transitioning to subcutaneous insulin [2].
Transition to Subcutaneous Insulin
- Overlap a subcutaneous basal‑bolus insulin regimen for 1–2 hours before stopping IV insulin [2].
- Use long‑acting basal insulin (e.g., glargine) at 0.2–0.3 units/kg/day and rapid‑acting insulin for meals, adjusting for the total daily dose previously given IV [2].
Identification and Treatment of Precipitating Causes
- Screen for infection, myocardial infarction, pancreatitis, medication non‑adherence, and SGLT2‑inhibitor use [2].
- Initiate appropriate antimicrobial therapy, cardiac evaluation, or medication cessation as indicated [2].
Common Pitfalls to Avoid
- Avoid delaying potassium repletion before insulin initiation, which can precipitate severe hypokalemia [2].
- Avoid maintaining the high‑dose 0.1 units/kg/h insulin infusion after glucose falls < 14 mmol/L, as this increases risk of hypoglycemia and cerebral edema [1].
- Avoid excessive bicarbonate administration; routine bicarbonate is not recommended unless pH < 6.9 [2].
Goals of Therapy
- Resolve acidosis (pH > 7.3, bicarbonate ≥ 18 mmol/L) within 12–24 hours [2].
- Normalize anion gap and serum ketones before discharge [2].
- Achieve stable glucose 100–150 mg/dL on a subcutaneous regimen with no recurrent ketosis [2].