What is the management protocol for Diabetic Ketoacidosis (DKA) in an Emergency Room (ER) setting?

Management of Diabetic Ketoacidosis in the Emergency Department

Immediate Diagnostic Workup

Upon arrival, confirm DKA diagnosis with blood glucose >250 mg/dL, arterial pH <7.3, serum bicarbonate <15 mEq/L, and positive ketones. 1, 2

Obtain immediately:

• Arterial blood gases, complete blood count with differential, urinalysis 1
• Blood glucose, electrolytes with calculated anion gap, serum ketones 1, 2
• Blood urea nitrogen, creatinine, chemistry profile 1
• Electrocardiogram 1
• Bacterial cultures (urine, blood, throat) if infection suspected 1

Initial Fluid Resuscitation

Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour during the first hour (approximately 1-1.5 liters in average adult). 1, 2

After the first hour, adjust fluids based on corrected sodium:

• If corrected sodium normal or elevated: use 0.45% NaCl at 4-14 mL/kg/hour 1
• If corrected sodium low: continue 0.9% NaCl at 4-14 mL/kg/hour 1
• Correct sodium for hyperglycemia by adding 1.6 mEq to measured sodium for each 100 mg/dL glucose above 100 mg/dL 1

When blood glucose reaches 250 mg/dL, switch to 5% dextrose with 0.45-0.75% NaCl to prevent hypoglycemia while continuing insulin. 3

Target complete fluid deficit correction within 24 hours, with osmolality change not exceeding 3 mOsm/kg/H2O per hour. 1

Insulin Therapy

Start continuous IV regular insulin at 0.1 units/kg/hour for moderate to severe DKA. 2, 3

• Do NOT give initial insulin bolus 1
• Target glucose decline of 50-75 mg/dL per hour 2, 3
• If glucose does not fall by 50 mg/dL in first hour, check hydration status and double insulin infusion rate hourly until steady decline achieved 3

Critical: Continue insulin infusion until DKA resolution regardless of glucose levels—do not stop when glucose normalizes. 2, 3

Potassium Management

This is life-threatening if mismanaged—monitor closely every 2-4 hours. 3

• If K+ <3.3 mEq/L: HOLD insulin therapy and aggressively replace potassium until ≥3.3 mEq/L to prevent fatal arrhythmias and respiratory muscle weakness 2, 3
• If K+ 3.3-5.5 mEq/L: Add 20-30 mEq/L potassium to IV fluids (use 2/3 KCl and 1/3 KPO4) once urine output confirmed 1, 3
• If K+ >5.5 mEq/L: Withhold potassium initially but monitor closely as levels will drop rapidly with insulin 3

Target serum potassium 4-5 mEq/L throughout treatment. 2, 3

Bicarbonate Administration

Do NOT give bicarbonate if pH >6.9-7.0. 2, 3

Studies show no benefit in resolution time or outcomes, and bicarbonate may worsen ketosis, cause hypokalemia, and increase cerebral edema risk. 2, 3 Consider only if pH <6.9 or in peri-intubation period to prevent hemodynamic collapse. 4

Monitoring Protocol

Draw blood every 2-4 hours for:

• Serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality 3
• Venous pH (typically 0.03 units lower than arterial pH) and anion gap 3

Monitor vital signs, neurologic status, fluid input/output continuously. 1, 2

Resolution Criteria

DKA is resolved when ALL of the following are met: 2, 3

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

Transition to Subcutaneous Insulin

Administer basal insulin (intermediate or long-acting) 2-4 hours BEFORE stopping IV insulin infusion to prevent recurrence of ketoacidosis and rebound hyperglycemia. 2, 3

Once patient can eat, start multiple-dose schedule with combination of short/rapid-acting and intermediate/long-acting insulin. 3

Alternative for Mild-Moderate Uncomplicated DKA

For alert patients with mild-moderate DKA, subcutaneous rapid-acting insulin analogs combined with aggressive fluid management may be equally effective, safer, and more cost-effective than IV insulin. 2, 3 However, continuous IV insulin remains standard for critically ill or mentally obtunded patients. 3

Identify and Treat Precipitating Factors

Search for and treat:

• Infection (most common—obtain cultures and start antibiotics if suspected) 1, 3
• Myocardial infarction, stroke, pancreatitis 2, 3
• Insulin omission or inadequacy 3
• SGLT2 inhibitor use (discontinue immediately and avoid 3-4 days before any surgery) 2, 3

Common Pitfalls to Avoid

• Premature termination of insulin before complete resolution of ketosis causes DKA recurrence 3
• Stopping insulin when glucose normalizes without adding dextrose worsens ketoacidosis 3
• Inadequate potassium monitoring and replacement is a leading cause of mortality 3
• Overly rapid osmolality correction increases cerebral edema risk, especially in children 3
• Starting insulin before adequate fluid resuscitation and potassium correction 5

Pediatric Modifications (<20 years)

Initial fluid: 0.9% NaCl at 10-20 mL/kg/hour (not to exceed 50 mL/kg over first 4 hours to minimize cerebral edema risk). 1 Insulin at 0.1 units/kg/hour after 1-2 hours of fluid resuscitation. 5