27th May 2025

Management

The three main principles of management are fluid replacement, insulin infusion and correction of electrolyte disturbances.

Fluid replacement 

• Isotonic saline is used initially, even if the patient is severely acidotic. 
• Most patients with DKA are extremely dehydrated and depleted of fluid up to 5-8 litres.
• A slower infusion rate should be considered in young adults aged 18-25 due to the risk of cerebral oedema and patients aged 16-18 should be managed by a paediatric team.

Table 1: Example regime of typical fluid replacement in DKA (adapted from JBDS guidelines) for patients with a systolic BP on admission of 90mmHg and over.

Insulin infusion

• A fixed rate intravenous insulin infusion (FRIII) should be started at a rate of 0.1 unit/kg/hr.
• When the blood glucose reaches <14mmol/L, an infusion of 10% dextrose at 125ml/hr should be started alongside the 0.9% sodium chloride FRIII. The rate of FRIII can be reduced to 0.05units/kg/hr to reduce the risk of hypoglycaemia and hypokalaemia.

Correction of electrolyte disturbance 

• Serum potassium is high in DKA but total body potassium is low. 
• Serum potassium will fall quickly with treatment with insulin and causes hypokalaemia. 
• Potassium should be replaced with the intravenous fluid replacement. 
• Cardiac monitoring should be considered if the potassium correction is more than 20mmol/hour.

Table 2: Guidance for potassium management outlined by the JBDS (adapted from JBDS guidelines)

Other principles of management:

• Identify and treat the underlying cause e.g. infection, myocardial infarction, intoxication. 
• Long-acting insulin should always be continued and short acting insulin should be stopped. 
• Involve the specialist diabetes team.
• Thromboprophylaxis.

Monitoring 

• Monitor the airway and consider a nasogastric tube to prevent aspiration secondary to gastric paresis and low GCS.
• Measure pH, venous bicarbonate, potassium, blood glucose and ketones at 0, 1, 2, 4, 6 and 12 hours whilst measuring blood glucose and ketones hourly for the first 6 hours and then at 12 hours.
• Monitor for improvement with the following:
  • Reduction of ketones by at least 0.5mmol/L/hr OR 
  • Increase of venous bicarbonate by at least 3mmol/L/hr AND 
  • Reduction in blood glucose of 3mmol/L/hr
• Monitor for cerebral oedema by assessing GCS hourly.
• Monitor for pulmonary oedema by monitoring for desaturation, obtain a chest x-ray if suspected and consider an arterial blood gas.
• Monitor fluid input and output, insert a urinary catheter if anuric after one hour of starting DKA treatment.

Resolution 

Three criteria need to be met to confirm resolution of DKA:

• pH >7.3 AND 
• Blood ketones 0.6 mmol/L AND 
• Bicarbonate >15mmol/L

Both the acidosis and ketonaemia should have resolved within 24 hours, if this has not occurred then a review from a senior endocrinologist is required. When the above criteria are met and the patient has started eating and drinking then the patient should be switched to subcutaneous insulin; this should be started with a meal and the FRIII should be continued for 30-60 minutes after this is started to permit a successful switch. If DKA has resolved but the patient is not eating and drinking then the patient can be switched to a variable rate intravenous insulin infusion (VRIII) and intravenous fluids should be continued. The patient should be reviewed by a diabetes specialist nurse before they are discharged.