From the Guidelines
Managing diabetic ketoacidosis (DKA) in the community when a patient refuses hospitalization is challenging and potentially dangerous, and the primary recommendation is to strongly encourage hospital admission, as community management carries significant risks. If the patient absolutely refuses hospitalization despite understanding the risks, emergency medical services should be contacted while attempting the following temporary measures:
- administer subcutaneous rapid-acting insulin at 0.1-0.2 units/kg initially, followed by 0.1 units/kg every 1-2 hours based on blood glucose monitoring, as there is no significant difference in outcomes for intravenous human regular insulin versus subcutaneous rapid-acting analogs when combined with aggressive fluid management for treating mild or moderate DKA 1;
- encourage oral rehydration with sugar-free fluids (1-2 liters in the first hour if possible, then 250-500 ml hourly);
- monitor blood glucose every 1-2 hours;
- check ketones if possible;
- and maintain electrolyte balance by consuming broths or electrolyte solutions. Blood glucose should be maintained between 150-250 mg/dl, avoiding rapid decreases. This approach is suboptimal because DKA requires intravenous fluids to correct dehydration, continuous insulin infusion for steady correction of ketosis, and close monitoring of electrolytes (particularly potassium) to prevent life-threatening complications, as stated in the most recent guidelines 1. Complications including cerebral edema, cardiac arrhythmias, and death may occur without proper hospital management. Community management should only be considered as a temporary bridge until the patient agrees to proper medical care. It is essential to treat any correctable underlying cause of DKA, such as sepsis, myocardial infarction, or stroke, and to provide individualization of treatment based on a careful clinical and laboratory assessment 1. The use of bicarbonate in patients with DKA is generally not recommended, as several studies have shown that it made no difference in the resolution of acidosis or time to discharge 1.