Suspected DKA in an adult (18 years and over)
Under 18, or cared for by a paediatric team: do not use this pathway. Use a paediatric DKA protocol (ISPAD 2022 or local).
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Emergency MedicineEmergency
Diabetic Ketoacidosis (DKA) in Adults (2024 Hyperglycaemic Crises Consensus)
Diabetic Ketoacidosis (DKA) in Adults (2024 Hyperglycaemic Crises Consensus): Suspected DKA in an adult (18 years and over) → Confirm DKA: D, K and A mu...
Pathway Overview
14 steps
Algorithm Steps
14 total
01Start 02Action Confirm DKA: D, K and A must all be present
Glucose can be below 11.1 mmol/L (euglycaemic DKA), mostly with SGLT2 inhibitors or in pregnancy.
- D: glucose 11.1 mmol/L or more, OR known diabetes at any glucose
- K: blood beta-hydroxybutyrate 3.0 mmol/L or more (urine ketones 2+ or more only if blood test not available)
- A: venous pH below 7.3 and/or bicarbonate below 18 mmol/L
- Tests now: VBG, glucose, blood ketones, UEC, FBC, ECG; cultures and other tests for the cause
- Very high glucose or osmolality: consider mixed DKA/HHS; lower glucose, sodium and osmolality slowly
03Warning Pregnancy, SGLT2 inhibitor, frailty, heart or kidney failure: modify care
Check for these before fluids and insulin.
- Pregnancy: call senior medical and obstetric teams now; care in HDU or delivery suite; DKA can occur at normal glucose
- SGLT2 inhibitor (e.g. empagliflozin, dapagliflozin): stop it; if glucose is below 14 mmol/L, give 5-10% glucose with the fluids from the start
- Older or frail, heart failure, dialysis: 250 mL fluid boluses and reassess after each; dialysis: K+ often high, get renal advice
04Action Grade severity and choose the level of care
Start treatment now. Do not wait for a bed. Not every criterion must be met.
- Mild: pH above 7.25 to below 7.30 or bicarbonate 15-18 mmol/L; alert. ED or ward with close monitoring
- Moderate: pH 7.0-7.25 or bicarbonate 10 to below 15 mmol/L; alert or drowsy. Step-down unit or HDU
- Severe: pH below 7.0, bicarbonate below 10 mmol/L, ketones above 6.0 mmol/L, or stupor or coma. ICU
- Also ICU: critical illness as the cause (e.g. MI, sepsis, GI bleeding)
05Action Step 1: IV fluids now
Start before insulin. Adults only (under 18: use a paediatric protocol). Smaller boluses if older, frail, pregnant, aged 18-25, or heart or kidney failure.
- SBP below 90 mmHg: 500 mL 0.9% sodium chloride over 10-15 min; repeat if still low and get senior and ICU review
- Then 0.9% sodium chloride or a balanced crystalloid (Hartmann's, Plasma-Lyte 148) 500-1000 mL/h for the first 2-4 h
- Then set the rate by BP, heart rate, fluid balance and sodium; correct the deficit over 24-48 h
- Older, frail, pregnant, heart or kidney failure: 250 mL boluses, reassess after each
- Mixed DKA/HHS: lower sodium and osmolality slowly; use 0.45% sodium chloride only if osmolality is not falling despite fluids and insulin
06Action Step 2: Potassium result before insulin
K+ 3.5 mmol/L or below: do not start insulin; replace potassium first. Add potassium to IV fluids only if the patient is passing urine. Target K+ 4-5 mmol/L.
- K+ 3.5 mmol/L or below: potassium chloride 10 mmol/h IV, cardiac monitoring and senior review; start insulin when K+ is above 3.5 mmol/L
- K+ above 3.5 and below 5.0 mmol/L and passing urine: add potassium chloride 20-30 mmol to each litre of IV fluid (not to resuscitation boluses)
- K+ above 3.5 mmol/L with no urine output (anuria) or on dialysis: no potassium in fluids; recheck K+ in 1 h; senior or renal advice
- K+ 5.0 mmol/L or above: no potassium; recheck K+ in 2 h
- K+ 6.5 mmol/L or above, or ECG changes: continuous ECG, senior review, IV calcium for ECG changes (hyperkalaemia protocol); continue this DKA protocol, as insulin lowers K+
- Rate limit: peripheral max 10 mmol/h and 40 mmol/L (e.g. 20 mmol/L at 500 mL/h); faster only with continuous ECG and central line in HDU or ICU (local policy)
07Action Step 3: Fixed-rate IV insulin 0.1 units/kg/h (only when K+ above 3.5 mmol/L)
Adult dose. Starting rate max 15 units/h (weight above 150 kg) unless the diabetes team advises. Do not stop insulin until DKA has resolved.
- Neutral (regular) insulin, e.g. Actrapid: 50 units made up to 50 mL with 0.9% sodium chloride (1 unit/mL), by syringe pump
- No routine bolus. IM insulin bolus only if the infusion will be delayed (dose: JBDS 2023 or local protocol)
- Glucose below 14 mmol/L: add 10% glucose 125 mL/h (or 5-10% glucose) and reduce insulin to 0.05 units/kg/h; aim for glucose about 11 mmol/L
- Continue usual long-acting insulin at the usual dose and time
- Mild or moderate DKA without complications: SC rapid-acting insulin every 1-2 h is an option only under a local protocol
08Action Bicarbonate: only if venous pH is below 7.0 (senior or ICU decision)
pH 7.0 or above: no bicarbonate. Not routine: it can cause hypokalaemia and cerebral oedema.
- Adult: sodium bicarbonate 8.4% 100 mL (100 mmol) in 400 mL sterile water over 2 h
- Repeat every 2 h only until pH is above 7.0
- Recheck K+; continue fluids, potassium and insulin
09Action Step 4: Monitor and adjust
Glucose and ketones every 1 h. VBG with K+ 2 h after insulin starts, then every 2-4 h.
- Targets: ketones fall at least 0.5 mmol/L/h (or bicarbonate rises 3 mmol/L/h, or glucose falls 3 mmol/L/h)
- Not on target: check the line and pump, then increase insulin by 1 unit/h each hour until on target
- Hypoglycaemia is common: keep the glucose infusion running. Glucose below 4 mmol/L: IV glucose per hospital protocol, recheck every 15 min, senior review of the insulin rate; ketosis still needs insulin
- Confusion, headache or falling GCS: urgent senior review and brain imaging (cerebral oedema)
- UEC daily; fluid balance; LMWH prophylaxis unless contraindicated
- Phosphate: replace only if below 1.0 mmol/L with muscle, breathing or heart weakness
10Action Find and treat the cause
Start this during treatment, not after.
- Infection (most common)
- Missed insulin, pump failure, or new diabetes
- MI, stroke, pancreatitis, PE, trauma; alcohol or drugs
- Medicines: SGLT2 inhibitors, corticosteroids, antipsychotics, immune checkpoint inhibitors
- Pregnancy
11Decision DKA resolved?
Resolved = blood ketones below 0.6 mmol/L AND venous pH 7.3 or more (or bicarbonate 18 mmol/L or more).
- Do not use the anion gap or urine ketones to judge resolution
- After large volumes of 0.9% sodium chloride, use pH, not bicarbonate (hyperchloraemic acidosis)
- If Yes
12Action Resolved: change to subcutaneous insulin
Change when the patient can eat and drink: give SC basal insulin 1-2 h before you stop the IV insulin. Not eating yet: continue IV fluids and a variable-rate IV insulin infusion with glucose.
- Known diabetes: restart the usual insulin; change the regimen now if HbA1c is high or a drug caused DKA
- Insulin-naive adult: total daily dose about 0.5-0.6 units/kg/day (about 0.3 units/kg/day if kidney failure or frailty) as basal-bolus; diabetes team to confirm
- SGLT2 inhibitor: do not restart routinely; not for type 1 diabetes
- Before discharge: diabetes team review, education, sick-day rules, ketone testing and follow-up
13Outcome DKA resolved
SC insulin started, cause treated, diabetes team follow-up arranged.
If No14Action Not resolved: continue insulin, glucose and fluids
Do not stop IV insulin. Repeat Step 4.
- Not resolved by 24 h: senior and diabetes specialist review
- Check the insulin line, pump and dose
- Path rejoins step 09Shared downstream outcome
Guideline Source
Hyperglycemic Crises in Adults With Diabetes: A Consensus Report (ADA, EASD, JBDS, AACE, DTS). Diabetes Care 2024;47(8):1257
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults only (18 years and over). Children and adolescents: use a paediatric DKA protocol.
- Pregnancy, SGLT2 inhibitor DKA, frailty, heart failure and dialysis need modified fluids and senior input; follow local hospital DKA protocols and IV potassium policy.
- Mixed DKA/HHS needs slower correction of glucose, sodium and osmolality.
- Doses are for adults; insulin infusion preparation and potassium limits vary by hospital.
Contraindicated Populations
Children and adolescents under 18 years, or any patient cared for by a paediatric team: use a paediatric DKA protocol (ISPAD 2022 or local)
Applicable Regions
AUUSEUUKInternational
AU: Follow the state or hospital adult DKA protocol and IV potassium policy (peripheral potassium usually max 10 mmol/h and 40 mmol/L). Neutral insulin (e.g. Actrapid) and Hartmann's or Plasma-Lyte 148 are available. Report glucose in mmol/L.
EU: EASD co-authored the 2024 consensus.
UK: JBDS-IP 2023: fixed-rate IV insulin 0.1 units/kg/h; add 10% glucose 125 mL/h when glucose is below 14 mmol/L and consider 0.05 units/kg/h; potassium 40 mmol/L of fluid when K+ is 3.5-5.5 mmol/L.
US: ADA 2024 consensus. Glucose thresholds 250 mg/dL = 13.9 mmol/L and 200 mg/dL = 11.1 mmol/L.
International: Adapt to local insulin and fluid availability; frequent potassium monitoring is essential.
Version 2Next review: 2027-09-30
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Frequently Asked Questions
What is the Diabetic Ketoacidosis (DKA) in Adults (2024 Hyperglycaemic Crises Consensus)?
The Diabetic Ketoacidosis (DKA) in Adults (2024 Hyperglycaemic Crises Consensus) is a emergency clinical algorithm for Emergency Medicine. It provides a structured decision tree to guide clinical decision-making, based on Hyperglycemic Crises in Adults With Diabetes: A Consensus Report (ADA, EASD, JBDS, AACE, DTS). Diabetes Care 2024;47(8):1257.
What guideline is the Diabetic Ketoacidosis (DKA) in Adults (2024 Hyperglycaemic Crises Consensus) based on?
This algorithm is based on Hyperglycemic Crises in Adults With Diabetes: A Consensus Report (ADA, EASD, JBDS, AACE, DTS). Diabetes Care 2024;47(8):1257 (DOI: 10.2337/dci24-0032).
What are the limitations of the Diabetic Ketoacidosis (DKA) in Adults (2024 Hyperglycaemic Crises Consensus)?
Known limitations include: Adults only (18 years and over). Children and adolescents: use a paediatric DKA protocol.; Pregnancy, SGLT2 inhibitor DKA, frailty, heart failure and dialysis need modified fluids and senior input; follow local hospital DKA protocols and IV potassium policy.; Mixed DKA/HHS needs slower correction of glucose, sodium and osmolality.; Doses are for adults; insulin infusion preparation and potassium limits vary by hospital.. Individual patient factors may require deviation from these recommendations.
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