What is the management of diabetic ketoacidosis (DKA) in the emergency department (ED)?

From the Guidelines

The management of diabetic ketoacidosis (DKA) in the emergency department requires prompt intervention with fluid resuscitation, insulin therapy, electrolyte replacement, and close monitoring, as outlined in the most recent guidelines 1.

Key Components of DKA Management

• Initial treatment begins with aggressive intravenous fluid resuscitation using 0.9% normal saline at 15-20 mL/kg/hr for the first hour (typically 1-2 L in adults), then adjusted based on hemodynamic status.
• Regular insulin should be administered as an IV bolus of 0.1 units/kg followed by a continuous infusion at 0.1 units/kg/hour.
• Potassium replacement is crucial when levels fall below 5.3 mEq/L, typically given as 20-30 mEq/L in IV fluids when urine output is confirmed.
• Once blood glucose reaches 200-250 mg/dL, IV fluids should be changed to D5W or D5 1/2NS to prevent hypoglycemia while continuing insulin to clear ketones.
• Bicarbonate therapy is generally reserved for severe acidosis (pH < 6.9), as its use has been shown to make no difference in the resolution of acidosis or time to discharge 1.

Monitoring and Underlying Cause Identification

• Throughout treatment, frequent monitoring of vital signs, mental status, glucose (hourly), electrolytes (every 2-4 hours), and arterial blood gases is essential.
• The underlying cause of DKA must be identified and treated, which commonly includes infection, medication non-compliance, or new-onset diabetes.

Recent Guidelines and Recommendations

• The most recent guidelines from 2025 1 emphasize the importance of individualizing treatment based on a careful clinical and laboratory assessment.
• Successful transition from intravenous to subcutaneous insulin requires administration of basal insulin 2–4 h before the intravenous insulin is stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia.
• Subcutaneous rapid-acting insulin analogs may be used in the emergency department or step-down units for patients with uncomplicated DKA, as they may be safer and more cost-effective than intravenous insulin 1.

From the Research

Management of Diabetic Ketoacidosis (DKA) in the Emergency Department (ED)

• The management of DKA in the ED involves several key components, including fluid hydration, insulin administration, and potassium replacement 2, 3, 4.
• Low-dose intravenous insulin has been shown to be a safe and effective treatment for DKA, with minimal complications such as hypoglycemia and hypokalemia 2.
• The use of isotonic saline and glucose solutions can help to replace extracellular and intracellular fluids, respectively 3.
• Potassium replacement is crucial to prevent hypokalemia, and can be achieved through the use of potassium chloride and/or potassium phosphate 2, 3.
• Close monitoring of serum glucose, potassium, and acid-base status is necessary to prevent complications and adjust treatment as needed 3, 5.

Treatment Protocols

• A standardized treatment protocol can help to reduce variability and improve safety in the management of DKA in the ED 6.
• Such protocols may include the use of computerized order entry systems and audit and feedback to ensure adherence to treatment guidelines 6.
• The protocol should be based on established treatment principles, including fluid hydration, insulin administration, and potassium replacement 2, 3, 4.

Clinical Considerations

• The severity of DKA should be classified based on the level of acidosis present, rather than absolute glucose level 5.
• The management of severe DKA requires careful assessment and treatment of the inciting event, as well as close monitoring to prevent complications such as cerebral edema and adult respiratory distress syndrome (ARDS) 5, 4.
• Near-patient testing of capillary beta-hydroxybutyrate (b-OHB) using a ketone meter can be a useful aid in managing and preventing DKA 4.