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

* 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)* 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* 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