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Diabetic Ketoacidosis – hyperglycemia, ketosis, and anion gap metabolic acidosis

  • Don’t forget about euglycemic DKA (especially in setting of SGLT2 inhibitor) or mimics such as alcoholic ketoacidosis
  1. Treatment of the ketoacidosis
    • Insulin (usually a drip or bolus + drip) – only once K>3.5
    • Volume Resuscitation (NS initially, change to LR)
    • Bicarb drip (poor evidence, only as last resort for critical patients)
  2. Treatment of electrolyte abnormalities
    • Correct sodium for hyperglycemia
    • Replete potassium if K<5.0, PO and IV simultaneously
      • consider central line if patient hypokalemic and in extremis/critical DKA
  3. Management of respiratory status
    • Avoid intubation at all costs unless altered or impending respiratory failure
      • APNEA KILLS
      • Mechanical ventilation limits your minute ventilation, leading to worsening acidosis. Breath stacking occurs if you set the RR too high.
    • Support work of breathing with NIPPV (high IPAP, low EPAP)
    • If intubation necessary, consider awake intubation or consider using bicarb pushes if performing RSI

Further Reading:

EMCRIT – DKA