What is the management of diabetic ketoacidosis (DKA) with a random blood sugar (RBS) level of hyperglycemia in the emergency room (ER)?

Emergency Management of DKA with Blood Glucose 600 mg/dL

Begin immediate aggressive fluid resuscitation with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour (approximately 1-1.5 L in the first hour) to restore circulatory volume and tissue perfusion, followed by continuous IV insulin infusion at 0.1 units/kg/hour once potassium is ≥3.3 mEq/L. 1, 2

Initial Assessment and Diagnosis

Confirm DKA diagnosis immediately by obtaining:

• Arterial or venous blood gas (pH <7.3 confirms DKA) 1, 3
• Serum glucose (>250 mg/dL diagnostic; your patient has 600 mg/dL) 4, 1
• Serum bicarbonate (<15 mEq/L) and calculate anion gap (>10-12 mEq/L) 1, 3
• Direct measurement of β-hydroxybutyrate in blood (preferred over urine ketones) 1, 2
• Complete metabolic panel, potassium level, BUN/creatinine, CBC, urinalysis, ECG 1, 2
• Bacterial cultures (blood, urine) if infection suspected 1, 2

Classify severity based on pH and bicarbonate, not glucose level:

• Mild: pH 7.25-7.30, bicarbonate 15-18 mEq/L 4, 3
• Moderate: pH 7.00-7.24, bicarbonate 10-15 mEq/L 4, 3
• Severe: pH <7.00, bicarbonate <10 mEq/L (requires ICU-level monitoring) 3

Fluid Resuscitation Protocol

Hour 1: Aggressive volume expansion

• Administer isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour 4, 1, 2
• This equals approximately 1-1.5 L for average adult in first hour 4, 1
• Monitor for cardiac compromise; adjust if heart failure or renal disease present 4

Subsequent hours: Adjust based on corrected sodium

• Calculate corrected sodium: add 1.6 mEq/L for every 100 mg/dL glucose above 100 4, 3
• If corrected sodium normal/elevated: switch to 0.45% NaCl at 4-14 mL/kg/hour 4
• If corrected sodium low: continue 0.9% NaCl at 4-14 mL/kg/hour 4
• When glucose falls to 250 mg/dL: add 5% dextrose to IV fluids while continuing insulin to clear ketones 1, 3

Critical pitfall to avoid: Do not allow induced change in serum osmolality to exceed 3 mOsm/kg/hour to prevent cerebral edema 2

Insulin Therapy

Do NOT start insulin if potassium <3.3 mEq/L - correct potassium first to prevent fatal arrhythmias 1, 3

Standard IV insulin protocol:

• Start continuous IV regular insulin infusion at 0.1 units/kg/hour (no bolus needed) 1, 2, 3
• If glucose does not fall by 50 mg/dL in first hour: double insulin infusion rate hourly until steady decline of 50-75 mg/dL per hour achieved 1, 2
• Continue insulin infusion until DKA resolves (pH >7.3, bicarbonate ≥18 mEq/L, anion gap ≤12 mEq/L), NOT just until glucose normalizes 1, 2

Alternative for mild-moderate uncomplicated DKA:

• Subcutaneous rapid-acting insulin analogs every 2-3 hours may be equally effective and safer 1, 5
• This is NOT appropriate for severe DKA or critically ill patients 1

Potassium Management

Check potassium BEFORE starting insulin - this is life-saving 1, 3

Potassium replacement algorithm:

• If K+ <3.3 mEq/L: HOLD insulin, give aggressive potassium replacement until ≥3.3 mEq/L to prevent cardiac arrest 1, 3
• If K+ 3.3-5.5 mEq/L: Add 20-30 mEq potassium per liter IV fluid (use 2/3 KCl and 1/3 KPO₄) once urine output confirmed 4, 1, 3
• If K+ >5.5 mEq/L: Withhold potassium initially but monitor closely every 2 hours, as levels will drop rapidly with insulin 1
• Target serum potassium 4-5 mEq/L throughout treatment 1, 2

Critical warning: Total body potassium is depleted in ALL DKA patients despite potentially normal/elevated initial levels due to acidosis 1, 2

Bicarbonate Therapy

Do NOT give bicarbonate if pH >7.0 - studies show no benefit and potential harm (worsening ketosis, hypokalemia, increased cerebral edema risk) 1, 2

Only consider bicarbonate if pH <6.9:

• Give 100 mmol sodium bicarbonate in 400 mL sterile water at 200 mL/hour 2
• Repeat pH in 2 hours 2

Monitoring Protocol

Every 2-4 hours during treatment, measure:

• Blood glucose (bedside and lab) 1, 2
• Serum electrolytes (sodium, potassium, chloride, bicarbonate) 1, 2
• Venous pH (adequate for monitoring; no need to repeat arterial sticks) 1, 3
• Calculate anion gap 1, 2
• BUN, creatinine, osmolality 1, 2
• β-hydroxybutyrate (preferred over urine ketones for monitoring response) 1, 2

Continuous cardiac monitoring to detect arrhythmias from electrolyte shifts 2

Resolution Criteria

DKA is resolved when ALL of the following are met:

• Glucose <200 mg/dL 1, 2, 3
• Serum bicarbonate ≥18 mEq/L 1, 2, 3
• Venous pH >7.3 1, 2, 3
• Anion gap ≤12 mEq/L 1, 2, 3

Target glucose 150-200 mg/dL during treatment until resolution criteria met 1

Transition to Subcutaneous Insulin

Critical timing to prevent rebound ketoacidosis:

• Give basal insulin (intermediate or long-acting) 2-4 hours BEFORE stopping IV insulin 1, 2, 3
• Once patient can eat, start multiple-dose regimen with short/rapid-acting plus intermediate/long-acting insulin 1, 2
• For newly diagnosed patients: initiate 0.5-1.0 units/kg/day total daily dose 2

Most common error: Stopping IV insulin when glucose normalizes but before ketoacidosis resolves leads to recurrent DKA 1, 6

Identify and Treat Precipitating Cause

Search for underlying triggers:

• Infection (most common) - obtain cultures, start antibiotics if indicated 1, 2
• Myocardial infarction - obtain troponin, ECG 1, 2
• Stroke or other acute illness 1, 2
• Medication non-adherence or insulin omission 1, 2
• SGLT2 inhibitors - discontinue immediately (can cause euglycemic DKA) 1, 2

Critical Complications to Monitor

Cerebral edema (rare but fatal, especially in children):

• Risk factors: higher BUN at presentation, rapid osmolality correction 2, 3
• Prevention: avoid glucose drop >75 mg/dL per hour, gradual osmolality correction 2
• Signs: headache, altered mental status, bradycardia 2

Hypokalemia - leading cause of mortality in DKA if inadequately monitored 1

Hypoglycemia - from continuing insulin without adding dextrose when glucose <250 mg/dL 1