Diabetic Ketoacidosis Treatment:

• At least at our academic medical center, we find it very hard to get a DKA patient admitted to an ICU or IMC while they are still in DKA.  Typically, we can correct the acidosis and downgrade them to a floor bed before their ICU/IMC bed is available.
• Some key points to remember when managing DKA in the ED.
  • The mainstay of treatment for the hyperglycemia initially is IV fluids.
  • Check labs often and replete Magnesium and Potassium early.
  • Insulin should not be started until the potassium is confirmed to be >3.3 mEq/L
  • Patients can still be in DKA even though there glucose is normal.
  • Intravenous insulin must be continued until all the ketones are cleared. 
  • Add D5W or D10 if needed to ensure that their glucose levels stay up but do not stop the insulin.
  • Patients need to receive a long acting insulin (i.e.: Lantus or NPH) 2 hours before the insulin drip is stopped.  Placing a patient only on Sliding Scale Insulin will almost guarantee that they go back into DKA on the floor.
  • Typically you can just restart the patients home long acting insulin, but if you are leary about hypoglycemia if they are not eating well, then give them 3/4 their home dose.

References

Charfen MA, Fernadez-Frackelton M. Diabetic Ketoacidosis. EMCNA 2005:609-628.