BoardsBridgeDKA in the Perioperative Patient
Recognition, intraoperative management, and crisis pitfalls when diabetic ketoacidosis collides with anesthesia and surgery
Perioperative DKA is an insulin-deficient, hyperosmolar, anion-gap metabolic crisis — driven by surgical stress, fasting, infection, or SGLT2 inhibitors — that demands fluid resuscitation, fixed-rate IV insulin 0.1 U/kg/h, aggressive K⁺ replacement (hold insulin if K⁺ <3.3 mEq/L), dextrose when glucose <250 mg/dL, and avoidance of bicarbonate unless pH <6.9.
If you forget
Headline: Fluids → K⁺ → Insulin → Dextrose — in that order, every time.
Board trap
Key numbers
- Insulin: 0.1 U/kg/h IV fixed-rate; reduce to 0.05 U/kg/h when glucose <250 mg/dL
- Hold insulin if serum K⁺ <3.3 mEq/L; replace to ≥3.3 before starting drip
- Add D5–D10 to 0.9% saline once glucose <250 mg/dL (13.9 mmol/L)
- Bicarbonate 100 mmol in 400 mL sterile water q2h only if pH <6.9, target pH >7.0
- DKA severity: mild β-OHB 3.0–6.0 mmol/L; severe β-OHB >6.0 mmol/L
- SGLT2 inhibitor hold: 3–4 days before elective surgery
- Cerebral edema mortality ~30%; treat with mannitol infusion + mechanical ventilation
- Recheck K⁺ 2 h after insulin start, then q4h until resolution
Uri Rozen, MD — Licensed Physician, Israel
Source guidelines: AHA ACC Perioperative Cardiovascular 2024 · ADA Hyperglycemic Crises 2024 · ADA Hyperglycemic Crises 2024 · ADA Hyperglycemic Crises 2024
Re-review cadence: 12 months from reviewed date.
Related on BoardsBridge
Card ID: dka-perioperative · Path: aba.critical-care.perioperative-metabolic-crises.dka-perioperative