Management of Diabetic Ketoacidosis

Initial Assessment and Treatment

The American College of Physicians recommends beginning immediate fluid resuscitation with isotonic saline at 15-20 mL/kg/hour, followed by continuous IV regular insulin at 0.1 units/kg/hour once serum potassium is ≥3.3 mEq/L, while identifying and treating precipitating factors including infection and ensuring SGLT2 inhibitors are discontinued if present 1, 2
Obtain laboratory tests immediately, including plasma glucose, serum ketones, electrolytes with calculated anion gap, arterial or venous blood gas, blood urea nitrogen, creatinine, osmolality, complete blood count with differential, urinalysis with urine ketones, and electrocardiogram 1, 2

Do not start insulin if serum potassium is <3.3 mEq/L, as this can cause life-threatening cardiac arrhythmias and death 1, 2
If K+ <3.3 mEq/L, continue isotonic saline but hold insulin, confirm adequate urine output, then aggressively replace potassium with 20-40 mEq/L in IV fluids 1

Start with 0.9% normal saline at 15-20 mL/kg/hour for the first hour, and subsequent fluid choice depends on hydration status, electrolyte levels, and urine output 1, 2
When glucose falls to 200-250 mg/dL, switch to 5% dextrose with 0.45-0.75% saline while continuing insulin infusion 1, 2

Once K+ ≥3.3 mEq/L, give IV bolus of 0.1 units/kg regular insulin, then start continuous infusion at 0.1 units/kg/hour regular insulin, targeting glucose decline of 50-75 mg/dL per hour 1, 2

Check every 2-4 hours: blood glucose, serum electrolytes, blood urea nitrogen, creatinine, osmolality, venous pH, and anion gap 1, 2

DKA is resolved when glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L 1, 2

Administer basal insulin 2-4 hours before stopping IV insulin infusion to prevent recurrence of ketoacidosis and rebound hyperglycemia 1, 2
Estimate total daily insulin requirement at 0.3-0.4 units/kg/day, with half as basal and half as prandial coverage 3

Discontinue SGLT2 inhibitors immediately if present, and do not restart until 3-4 days after metabolic stability achieved 2
Infection is the most common DKA precipitant, and lung cancer patients are at higher infection risk 2
Obtain chest X-ray given lung cancer history and administer appropriate antibiotics if infection confirmed 1, 2