Diabetic Ketoacidosis (DKA) Management (ADA 2024)

Algorithm Steps

1. ▶

   Start

   Suspected DKA

   Hyperglycemia + ketosis + acidosis

   1. ●

      Action

      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
      1. ●

         Action

         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]
         1. ●

            Action

            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
            1. ⚠

               Warning

               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
               1. ●

                  Action

                  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
                  1. ●

                     Action

                     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)
                     1. ●

                        Action

                        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
                        1. ●

                           Action

                           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
                           1. ✓

                              Outcome

                              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
               2. ●

                  Action

                  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