REBEL Core Cast 18.0 – DKA Tips and Tricks

Take Home Points

  • When looking at pH and bicarb, the differences between VBG and ABG are miniscule. For DKA patients, stick with the VBG as is less painful and has fewer complications. 
  • LR is probably a better fluid for the large volume resuscitation required in DKA. Start with a 20 cc/kg bolus and then reassess the patient’s perfusion status.
  • Stay on top of your electrolyte repletion. If the patient has a working gut, you can aggressively replete potassium orally and don’t forget that when you are repleting potassium you also must replete magnesium.
  • Bolus dose insulin gets the patient to super-physiologic levels and has been associated with higher potassium requirements and more episodes of hypoglycemia. It’s probably fine to skip the bolus and stick with a drip alone
  • Don’t forget to think of all possible etiologies of DKA, while we most often find this in patients who have not been taking their home meds for whatever reason, don’t forget a good history to look for sources such as infection and ischemia. 

REBEL Core Cast 18.0 – DKA Tips and Tricks

Click here for Direct Download of Podcast

Show Notes

Diagnostic Criteria

  • Hyperglycemia
  • Acidosis
  • Ketosis

Do we need an ABG? Nah 

  • pH mean difference between abg and vbg was 0.02 pH units. PMID: 21143397
  • Bicarb had a difference of -1.41 mmol/L. PMID: 21143397
  • pCO2 had a difference of about -6 mmHg
  • Not important to know the differences but rather the fact that the differences are irrelevant both in diagnosis and treatment

How much and what kind of fluids?

  • Patients are about 5-10% fluid down which is moderate dehydration
    • If hypotensive, more dehydrated and will need more fluid
  • The standard fluid resuscitation is 20-30cc/kg normal saline. Should it be the standard though?
    • NS is 154 mEq of Na & Cl with a pH of ~5.7, not ideal for acidotic patient
    • NS bolus can lead to non-anion gap hyperchloremic metabolic acidosis stacking on the anion gap acidosis. 
  • Reach for a more balanced solution like Lactated Ringers or Plasmalyte
    • LR is 130 mEq of NA, 130 Cl, 4 K, 1.5 Ca with a pH of ~6.4

Cerebral Edema

  • Volume of fluid will likely not lead to cerebral edema PMID: 29897851


  • Bicarbonate boluses never shown to be beneficial.
  • Isotonic bicarbonate infusion may be helpful. The BICAR-ICU study showed decreased necessity for dialysis in patients treated with isotonic bicarbonate (secondary endpoint)

Electrolyte Derangement

  • Total body potassium deficient 
  • Acidosis causes potassium to shift out of cells and falsely elevated serum levels
  • If gut working, give PO (40 mEq) & IV (10-20 mEq)
  • If Low K, then assume Low Mg

When to start Insulin

  • K above 3.5, start insulin with K infusion
  • K less than 3.5, hold insulin and give K
  • No bolus dosing, just give infusion (0.1 units /kg) and give their basal insulin
  • Don’t forget to look for underlying cause of DKA!!


Shownotes Written By: Miguel Reyes, MD (Twitter: @miguel_reyesMD)

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

Cite this article as: Anand Swaminathan, "REBEL Core Cast 18.0 – DKA Tips and Tricks", REBEL EM blog, September 25, 2019. Available at:
The following two tabs change content below.

Anand Swaminathan

Clinical Assistant Professor of Emergency Medicine at St. Joe's Regional Medical Center (Paterson, NJ)
REBEL EM Associate Editor and Author

Like this article?

Share on facebook
Share on Facebook
Share on twitter
Share on Twitter
Share on linkedin
Share on Linkdin
Share on email
Share via Email

Want to support rebelem?

Leave a Comment

Time limit is exhausted. Please reload CAPTCHA.