What is the initial treatment for a patient with Diabetic Ketoacidosis (DKA) and an anion gap of 33, with a Blood Glucose Level (BGL) of 294?

Initial Treatment for DKA with Anion Gap 33 and Blood Glucose 294 mg/dL

Begin immediate fluid resuscitation with isotonic saline (0.9% NaCl) at 15-20 ml/kg/hour (approximately 1-1.5 L in the first hour), obtain stat potassium level before starting insulin, and once potassium is ≥3.3 mEq/L, initiate IV regular insulin at 0.1 units/kg/hour continuous infusion. 1

Immediate Fluid Resuscitation (First Priority)

• Start with isotonic saline (0.9% NaCl) at 15-20 ml/kg/hour during the first hour to restore circulatory volume and tissue perfusion 1
• This patient requires aggressive volume replacement as total fluid deficit is typically 6L or 100 ml/kg in DKA, to be corrected within 24 hours 1
• Continue isotonic saline until hemodynamic stability is achieved 2

Critical Potassium Assessment (Before Insulin)

• Obtain serum potassium level immediately and DO NOT start insulin until you know the result 3
• If potassium is <3.3 mEq/L, delay insulin therapy and aggressively replace potassium first to prevent fatal cardiac arrhythmias 3, 1
• If potassium is ≥3.3 mEq/L, proceed with insulin therapy 2
• Despite total-body potassium depletion, initial levels may appear normal or elevated due to acidosis and insulin deficiency 2, 1

Insulin Therapy Initiation

• Start continuous IV regular insulin infusion at 0.1 units/kg/hour (no bolus necessary in adults) 1
• Alternative approach includes 0.15 U/kg bolus followed by 0.1 U/kg/hour infusion, though some studies show no benefit to the bolus 1, 4
• Continue insulin infusion until DKA resolves: glucose <200 mg/dL, bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L 1

Potassium Replacement During Treatment

• Once potassium falls below 5.5 mEq/L (assuming adequate urine output), add 20-30 mEq potassium to each liter of IV fluid 2, 1
• Use 2/3 KCl and 1/3 KPO4 in the replacement solution 2
• Target serum potassium of 4-5 mEq/L throughout treatment 2

Glucose Management

• When blood glucose falls to 250 mg/dL, add dextrose (5% dextrose in 0.45% or 0.9% saline) to IV fluids to prevent hypoglycemia 5
• Do not stop insulin when glucose normalizes—continue insulin infusion until ketoacidosis resolves (anion gap ≤12 mEq/L, bicarbonate ≥18 mEq/L) 6
• This patient's relatively lower glucose (294 mg/dL) means dextrose may need to be added earlier in treatment 7

Bicarbonate Therapy (Likely Not Needed)

• With anion gap of 33, the pH is likely <7.0, but bicarbonate is only indicated if pH <6.9 2, 1
• If pH is 6.9-7.0, give 50 mmol sodium bicarbonate in 200 ml sterile water at 200 ml/h 2
• If pH <6.9, give 100 mmol sodium bicarbonate in 400 ml sterile water at 200 ml/h 2
• No bicarbonate is necessary if pH ≥7.0 2

Monitoring Requirements

• Check blood glucose every 1-2 hours 3
• Draw venous blood gases, electrolytes, BUN, creatinine every 2-4 hours 3
• Monitor venous pH and anion gap to track resolution of acidosis 3
• Continue monitoring β-hydroxybutyrate (preferred over urine ketones) until normalized 3

Search for Precipitating Cause

• Most common precipitant is infection—obtain complete blood count, urinalysis, chest X-ray, and blood cultures 1, 4
• Other causes include insulin omission, new-onset diabetes, myocardial infarction, pancreatitis, medications (corticosteroids, SGLT-2 inhibitors) 1, 7, 4
• Administer appropriate antibiotics if infection is identified 1

Critical Pitfalls to Avoid

• Never start insulin before knowing the potassium level—hypokalemia can cause fatal arrhythmias or respiratory muscle weakness 2, 3
• Never stop insulin infusion prematurely when glucose normalizes—continue until anion gap closes and bicarbonate normalizes to prevent rebound ketoacidosis 6
• Don't rely on urine ketones for monitoring—they are unreliable and misleading during treatment 3
• Don't assume normal temperature rules out infection—patients with DKA can be normothermic despite serious infection 3