Diabetic Ketoacidosis Management (ADA/EASD/JBDS 2024 Consensus)

Algorithm Steps

1. ▶

   Start

   Suspected DKA

   Hyperglycemia + Ketosis + Acidosis

   1. ●

      Action

      Confirm DKA Diagnosis

      Check diagnostic criteria

      • Glucose: typically >250 mg/dL (may be lower in euglycemic DKA)
      • pH <7.3 and/or HCO3 <18 mEq/L
      • Ketones: β-hydroxybutyrate >3.0 mmol/L or urine ketones moderate-large
      • Anion gap >10-12
      • Consider euglycemic DKA if on SGLT2 inhibitor
      1. ◆

         Decision

         Assess DKA Severity

         Mild/Moderate vs Severe

         • MILD: pH 7.25-7.30, HCO3 15-18, alert
         • MODERATE: pH 7.0-7.24, HCO3 10-14, alert/drowsy
         • SEVERE: pH <7.0, HCO3 <10, stupor/coma
         1. ●

            Action

            1. IV Fluid Resuscitation

            Start immediately - do not delay for insulin

            • 0.9% NaCl: 1-1.5 L in first hour (15-20 mL/kg)
            • Then 250-500 mL/hr based on hydration status
            • Switch to 0.45% NaCl if corrected Na+ normal/elevated
            • Add D5 when glucose <200 mg/dL
            • Typical deficit: 3-6 liters
            1. ◆

               Decision

               Serum K+ Level?

               Check K+ BEFORE starting insulin

               • Total body K+ depleted despite serum level
               • K+ will drop rapidly with insulin therapy
               1. ⚠

                  Warning

                  K+ <3.3 mEq/L

                  HOLD INSULIN until K+ ≥3.3

                  • Replace K+ aggressively (20-40 mEq/hr)
                  • Cardiac monitoring essential
                  • Recheck K+ every 1-2 hours
                  • DO NOT give insulin until K+ ≥3.3
                  1. ●

                     Action

                     2. Insulin Therapy

                     Start after fluid bolus and K+ assessment

                     • Regular insulin IV: 0.1 units/kg bolus, then 0.1 units/kg/hr
                     • OR 0.14 units/kg/hr continuous (no bolus)
                     • Target glucose drop: 50-70 mg/dL/hr
                     • If glucose not falling, double rate
                     • When glucose <200, reduce to 0.02-0.05 units/kg/hr + D5
                     1. ◆

                        Decision

                        pH <6.9?

                        Consider bicarbonate only in severe acidosis

                        1. ●

                           Action

                           Bicarbonate Therapy

                           For pH <6.9 only (controversial)

                           • 100 mEq NaHCO3 in 400 mL water + 20 mEq KCl
                           • Infuse over 2 hours
                           • Repeat if pH still <7.0
                           • NOT recommended if pH ≥6.9
                           1. ●

                              Action

                              Ongoing Monitoring

                              Frequent labs and clinical assessment

                              • BMP: every 2-4 hours initially
                              • Glucose: every 1 hour
                              • β-hydroxybutyrate: every 2-4 hours (preferred over anion gap)
                              • Venous pH: every 2-4 hours until stable
                              • Fluid balance, urine output, mental status
                              1. ●

                                 Action

                                 Identify Precipitant

                                 The 5 I's and other causes

                                 • Infection (UTI, pneumonia, skin)
                                 • Infarction (MI, stroke)
                                 • Insulin omission/non-adherence
                                 • Intoxication (alcohol, drugs)
                                 • Infant (pregnancy)
                                 • Also: new-onset T1DM, pancreatitis, meds (steroids, SGLT2i)
                              2. ◆

                                 Decision

                                 DKA Resolution?

                                 All criteria must be met

                                 • Glucose <200 mg/dL
                                 • Anion gap <12 OR β-hydroxybutyrate <0.6 mmol/L
                                 • pH ≥7.3 and HCO3 ≥15
                                 • Patient able to eat
                                 1. ●

                                    Action

                                    Transition to SubQ Insulin

                                    Overlap IV and SubQ by 1-2 hours

                                    • Give basal insulin (glargine/detemir) 1-2 hrs before stopping drip
                                    • Calculate total daily dose based on drip rate
                                    • Resume home regimen if appropriate
                                    • NEW diagnosis: 0.5-0.8 units/kg/day total
                                    • Identify and treat precipitant
                                    1. ✓

                                       Outcome

                                       DKA Resolved

                                       Continue monitoring, diabetes education

               2. ●

                  Action

                  K+ 3.3-5.3 mEq/L

                  Add K+ to fluids + start insulin

                  • Add 20-30 mEq KCl per liter of fluid
                  • Target K+ 4-5 mEq/L
                  • Monitor K+ every 2-4 hours
               3. ●

                  Action

                  K+ >5.3 mEq/L

                  Hold K+, start insulin, recheck frequently

                  • Do not add K+ to fluids initially
                  • K+ will drop with insulin/fluids
                  • Recheck every 2 hours
                  • ECG monitoring
         2. ✓

            Outcome

            Complicated Course

            ICU for severe DKA, cerebral edema, ARDS