I can think of few conditions easier to diagnose and disposition as diabetic ketoacidosis (DKA): A single venous blood gas from triage will clinch both the diagnosis as well as an acceptance to the intensive care unit (ICU) from even the most curmudgeonly intensivist. In this month’s Critical Care Time, I’ll try to lay out a few high-yield pearls in the management of DKA learned from my time upstairs managing these patients beyond the first few hours.

Fluids

Often, you’ll suspect the DKA diagnosis even before the confirmatory metabolic panel is back. It can feel like it takes an eternity for the results as the lab double- and triple-checks the abnormal values while you impatiently wait to initiate your insulin drip. During this limbo, however, you can make significant headway in the resuscitation with intravenous (IV) fluids. Virtually all of these patients are significantly hypovolemic from multiple sources. The nausea, vomiting, and abdominal pain associated with the ketosis result in decreased oral intake while the osmotic load of the glucosuria further dehydrates the patient via polyuria. One British society guideline estimates that a 70 kg adult may have as much as a 7 L fluid deficit! ¹

As such, I will typically start with a bolus of 2-3 liters while waiting for the labs to come back. By dilution alone, the fluids will start to improve the hyperglycemia, often by several hundred mg/dL, even before starting insulin, and may decrease the cortisol that worsens insulin resistance.² So, what fluid to use? Although the aforementioned curmudgeonly intensivist may drone on and on about the concomitant chloride loss and metabolic alkalosis from the vomiting, most of us who manage the patient in the emergency department (ED) won’t even have the metabolic panel back, so keep it simple: Lactated Ringer’s (LR) for everyone. LR leads to faster resolution of DKA with shorter hospital length of stay.^3–5 Large volumes of normal saline, on the other hand, can cause a hyperchloremic metabolic acidosis that, in addition to causing renal arteriolar vasoconstriction and oliguria, can produce its own anion-gap acidosis that frustratingly prevents you from “closing the gap.”¹ Take home message: For most patients in DKA, start with at least 2-3 L of LR while you are waiting for the labs to come back.

For most patients in DKA, start with at least 2-3 L of LR while you are waiting for the labs to come back.

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