← Diagnosis and Management Guides
Diabetic Ketoacidosis
Key considerations: Sepsis as trigger, MI as trigger, Euglycemic DKA (SGLT2 inhibitors)
Cannot miss
- Sepsis as trigger
- MI as trigger
- Euglycemic DKA (SGLT2 inhibitors)
Likely diagnoses
- DKA from non-compliance
- DKA from new-onset DM
- Starvation ketosis
- Alcoholic ketoacidosis
Red flags
- pH <7.0
- Altered mental status
- Potassium <3.3
- Cerebral edema (pediatric)
Workup
- history: Insulin compliance, illness, SGLT2 inhibitor use; exam: Kussmaul respirations, acetone breath, dehydration; labs: BMP (anion gap), glucose, VBG/ABG, serum ketones, CBC, lipase, UA; imaging: CXR if infection suspected; bedside: Point-of-care glucose and ketones
Management
- immediate: IV NS 1-2L/hr initially; Insulin drip 0.1 units/kg/hr (after K >3.3); Replete K aggressively (goal 4-5 mEq/L); general: Add D5 to fluids when glucose <250; Close anion gap before stopping insulin drip; Overlap SQ insulin 2hr before stopping drip; Identify and treat precipitant
Disposition
- admit: All DKA patients (ICU if pH <7.1 or severe); discharge: After anion gap closed, tolerating PO, on SQ insulin; consults: Endocrinology for new-onset or recurrent DKA
Clinical pearls
- K must be >3.3 before starting insulin — insulin drives K intracellularly and can cause fatal hypokalemia
- Check anion gap, not glucose, to determine resolution — glucose normalizes before acidosis resolves
Source and review
- ADA DKA Management Standards 2024. Last reviewed: 2024-11-01