Suspected DKA
Hyperglycemia + ketosis + acidosis
All Pathways
EndocrinologyEmergency
Diabetic Ketoacidosis (DKA) Management (ADA 2024)
Diabetic Ketoacidosis (DKA) Management (ADA 2024): Suspected DKA → Diagnostic Criteria → Initial Labs → Identify Precipitant → Fluid Resuscitation (STAR...
Pathway Overview
11 steps
Algorithm Steps
11 total
01Start 02Action Diagnostic Criteria
Confirm DKA diagnosis
- TRIAD:
- 1. Hyperglycemia: Glucose >250 mg/dL
- (Can be euglycemic with SGLT2i)
- 2. Ketosis: Serum/urine ketones +
- (Beta-hydroxybutyrate >3 mmol/L)
- 3. Acidosis: pH <7.3, HCO3 <18 mEq/L
- SEVERITY:
- - Mild: pH 7.25-7.3, HCO3 15-18
- - Moderate: pH 7.0-7.24, HCO3 10-15
- - Severe: pH <7.0, HCO3 <10
03Action Initial Labs
Comprehensive metabolic assessment
- STAT labs:
- - BMP (glucose, K+, HCO3, BUN, Cr)
- - VBG or ABG (pH, pCO2)
- - Beta-hydroxybutyrate
- - Serum osmolality
- - CBC
- - UA with ketones
- CALCULATE:
- - Anion gap = Na - (Cl + HCO3)
- - Normal: 8-12
- - DKA: Usually >20
- - Corrected Na+ = Measured + 1.6×[(glucose-100)/100]
04Action Identify Precipitant
The '5 I's'
- INFECTION (most common)
- - UTI, pneumonia, skin
- - COVID-19, influenza
- INSULIN (missed doses/pump failure)
- INFARCTION (MI, stroke, mesenteric)
- INTOXICATION (cocaine, alcohol)
- INITIAL PRESENTATION (new T1DM)
- Other: Pregnancy, steroids, pancreatitis
05Warning Fluid Resuscitation (START FIRST)
IV fluids are priority #1
- INITIAL BOLUS:
- - 0.9% NS: 15-20 mL/kg/hr (1-1.5L) first hour
- SUBSEQUENT:
- - If corrected Na+ low: 0.9% NS at 250-500 mL/hr
- - If corrected Na+ normal/high: 0.45% NS at 250-500 mL/hr
- WHEN GLUCOSE <200 mg/dL:
- - Switch to D5-0.45% NS
- - Maintain glucose 150-200 mg/dL
- GOAL: 3-6L in first 24h typically
06Action Potassium Replacement
Critical - check before insulin
- BEFORE INSULIN:
- - K+ <3.3: HOLD insulin, give 20-30 mEq/hr
- - K+ 3.3-5.2: Add 20-30 mEq to each liter fluid
- - K+ >5.2: Do not give K+, recheck q2h
- GOAL: K+ 4-5 mEq/L
- MONITORING:
- - Q2h initially with insulin
- - ECG if K+ <3 or >6
- NOTE: Total body K+ depleted even if serum normal
07Action Bicarbonate (Rarely Needed)
Only for severe acidosis
- INDICATIONS (controversial):
- - pH <6.9 (some say <7.0)
- - Severe hyperkalemia with ECG changes
- - Hemodynamic instability
- IF GIVEN:
- - 100 mEq NaHCO3 in 400 mL water + 20 mEq KCl
- - Infuse over 2 hours
- - Repeat if pH remains <7.0
- AVOID routine use (may worsen outcomes)
08Action Monitoring
Frequent reassessment
- GLUCOSE: Q1h
- ELECTROLYTES: Q2-4h initially
- ANION GAP: Q4h (calculate from BMP)
- VBG/ABG: Q2-4h until stable
- CLINICAL: Mental status, I/O
- RESOLUTION CRITERIA:
- - Anion gap <12
- - pH >7.3
- - HCO3 ≥15
- - Patient eating
09Action Transition to SubQ Insulin
When DKA resolved
- CRITERIA TO TRANSITION:
- - Anion gap normalized
- - pH >7.3
- - Tolerating PO
- OVERLAP:
- - Give SubQ basal insulin
- - Continue IV insulin 1-2 hours after SubQ
- - Then discontinue drip
- NEW DIABETIC:
- - Start 0.5-0.8 U/kg/day total
- - 50% basal, 50% prandial
10Outcome Outcomes
Follow-up
- Mortality: <1% with proper treatment
- Cerebral edema: <1% adults (higher in peds)
- Education before discharge
- Sick day rules
- Endocrine follow-up
- Address precipitant
11Action Insulin Therapy
Start after K+ confirmed >3.3
- REGULAR INSULIN IV DRIP:
- - 0.1 U/kg/hr (no bolus per ADA 2024)
- - OR: 0.14 U/kg/hr if no initial bolus
- TARGET:
- - Glucose drop: 50-70 mg/dL/hr
- - If not dropping: Double rate
- WHEN GLUCOSE <200 mg/dL:
- - Reduce to 0.02-0.05 U/kg/hr
- - Add D5 to fluids
- - Maintain glucose 150-200
- DO NOT STOP INSULIN until anion gap closes
- Path rejoins step 07Shared downstream outcome
Guideline Source
ADA Standards of Care in Diabetes 2024 + JBDS DKA Guidelines
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Pediatric dosing differs
- Cerebral edema risk (especially pediatric)
- Euglycemic DKA with SGLT2 inhibitors
- Must identify precipitant
Applicable Regions
USEU
Version 1Next review: 2027-01-11
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Related Resources
Frequently Asked Questions
What is the Diabetic Ketoacidosis (DKA) Management (ADA 2024)?
The Diabetic Ketoacidosis (DKA) Management (ADA 2024) is a emergency clinical algorithm for Endocrinology. It provides a structured decision tree to guide clinical decision-making, based on ADA Standards of Care in Diabetes 2024 + JBDS DKA Guidelines.
What guideline is the Diabetic Ketoacidosis (DKA) Management (ADA 2024) based on?
This algorithm is based on ADA Standards of Care in Diabetes 2024 + JBDS DKA Guidelines (DOI: 10.2337/dc24-SINT).
What are the limitations of the Diabetic Ketoacidosis (DKA) Management (ADA 2024)?
Known limitations include: Pediatric dosing differs; Cerebral edema risk (especially pediatric); Euglycemic DKA with SGLT2 inhibitors; Must identify precipitant. Individual patient factors may require deviation from these recommendations.
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