SEVERE DIABETIC KETOACIDOSIS: UPDATES IN FLUID RESUSCITATION, INSULIN THERAPY, AND ELECTROLYTE MANAGEMENT

Abstract

Severe diabetic ketoacidosis is a potentially life-threatening metabolic emergency characterized by marked ketonemia, metabolic acidosis, and significant disturbances in circulating volume and electrolytes. Treatment is based on fluid replacement, insulin therapy, correction of hydroelectrolytic abnormalities, and identification of precipitating factors. This review aimed to analyze recent evidence on the management of severe diabetic ketoacidosis in adults, with emphasis on fluid selection, insulin strategies, and electrolyte replacement. An integrative literature review was conducted considering publications from September 2021 to September 2026, with searches performed in PubMed/MEDLINE, Scopus, Web of Science, and ScienceDirect. A total of 886 records were identified, and after screening and eligibility assessment, 19 publications were included in the final qualitative synthesis. Current evidence suggests that balanced crystalloids may reduce hyperchloremia and improve acid-base parameters, although their superiority regarding time to DKA resolution remains inconsistent. Intravenous insulin remains the recommended strategy for severe cases, while early basal insulin administration has shown promising but heterogeneous results across studies. Close potassium monitoring remains essential, whereas routine bicarbonate and phosphate replacement is not recommended. In conclusion, individualized protocols and frequent clinical and biochemical monitoring remain essential to reduce complications and improve treatment safety.