Clinical Pearls and Pitfalls
· Euglycemic DKA is increasingly prevalent; avoid overreliance on hyperglycemia while diagnosing DKA.
· Serum β-hydroxybutyrate is preferable to urinary ketones.
· Mixed acid-base disorders are common at DKA presentation, and over-reliance on strict laboratory-based definitions of DKA can result in missed diagnosis.
· Use balanced crystalloids for fluid resuscitation to reduce time to DKA resolution.
· The two-bag method of fluid administration reduces time to DKA resolution and incidence of hypoglycemia in both adults and pediatrics.
· Correct hypokalemia before starting insulin.
· An insulin bolus at the start of insulin infusion is not necessary in adults and is not recommended in children. Subcutaneous insulin protocols can be used for mild or moderate DKA.
· Start dextrose when glucose level is less than 250 mg/dL (13.9 mmol/L), not when acidosis resolves.
· Bicarbonate should not routinely be administered, except in very specific scenarios.
· ED disposition varies based on DKA severity and institutional protocols, and opportunity exists to safely reduce ICU admissions for DKA.
