DKA = diabetes or glucose ≥ 200 mg/dL + β-hydroxybutyrate ≥ 3.0 mmol/L (or urine ketones ≥ 2+) + pH < 7.3 and/or HCO3- < 18. Treat with fluids, fixed-rate insulin 0.1 units/kg/h once K+ ≥ 3.5, potassium replacement, and dextrose once glucose < 250 mg/dL until ketones clear.
At the bedside
Timed steps- 1
Fluids
0-1 h0.9% saline or balanced crystalloid 500-1000 mL/h for the first 2-4 h (250 mL boluses if elderly, heart or kidney failure). Balanced fluids resolve DKA faster with less hyperchloraemia.
- 2
Potassium first
0-1 hK+ < 3.5: give KCl 10 mmol/h and delay insulin until > 3.5. K+ 3.5-5.0: add 20-30 mmol KCl per litre to keep 4-5. K+ > 5.0: no K+, recheck in 2 h.
- 3
Insulin
1 hFixed-rate IV regular insulin 0.1 units/kg/h (0.1 units/kg bolus if access delayed). Continue the patient's basal insulin; or start basal 0.15-0.3 units/kg SC early.
- 4
Glucose < 250 mg/dL
OngoingAdd 5-10% dextrose and reduce insulin to 0.05 units/kg/h; keep glucose ~200 mg/dL; never stop insulin while ketotic. Euglycaemic DKA: start dextrose with the saline from the outset.
- 5
Every 1-2 h / 4 h
MonitorCapillary glucose hourly; K+ at 2 h then 4-hourly; electrolytes, β-hydroxybutyrate, venous pH every 4 h.
- 6
Only pH < 7.0
Bicarbonate100 mmol 8.4% in 400 mL water over 2 h, repeat until pH > 7.0. Phosphate only if < 1.0 mg/dL with weakness.
- 7
Then transition
ResolutionKetones < 0.6 mmol/L and venous pH ≥ 7.3 or HCO3- ≥ 18. Give SC basal-bolus insulin (0.5-0.6 units/kg/day; 0.3 if frail/CKD), overlap 1-2 h before stopping IV insulin.
DKA fixed-rate infusion
Regular (soluble) insulin infusion
- Dose
- 0.1 units/kg/h; reduce to 0.05 units/kg/h when glucose < 250 mg/dL with dextrose added
- Worked example
- 60 kg: 6 units/h (6 mL/h of 1 unit/mL) → 3 units/h with 10% dextrose once glucose < 250
DKA with pH < 7.0
Sodium bicarbonate
- Dose
- 100 mmol (100 mL 8.4%) in 400 mL sterile water over 2 h, repeat to pH > 7.0
DKA severity (ADA 2024)
| Mild | Moderate | Severe | |
|---|---|---|---|
| β-hydroxybutyrate | 3.0-6.0 mmol/L | 3.0-6.0 mmol/L | > 6.0 mmol/L |
| pH | 7.25-7.30 | 7.0-7.25 | < 7.0 |
| Bicarbonate | 15-18 | 10-15 | < 10 |
| Mental status | Alert | Alert/drowsy | Stupor/coma |
| Level of care | Ward/observation | Step-down/HDU | ICU |
Not all variables need to be met; level of care is a clinical decision. Mild-moderate DKA can be treated with hourly-2-hourly SC rapid-acting analogues.
Calculators for this topic
DKA first hours
Step 1 of ~8
Crystalloid 500-1000 mL/h
Based on Umpierrez GE, Davis GM, ElSayed NA, et al. Educational use; follow local protocol.
Pathophysiology
- Insulin deficiency plus counter-regulatory hormones drive lipolysis and ketogenesis; osmotic diuresis causes total-body K+ deficit of 3-6 mmol/kg even if serum K+ is high.
Evidence
- ADA/EASD/JBDS/AACE/DTS 2024 consensus: new glucose threshold (≥ 200 mg/dL or known diabetes), β-hydroxybutyrate-based diagnosis and resolution, balanced crystalloids acceptable.
Controversies
- Early SC basal insulin during IV infusion shortens time to resolution in small studies without more hypoglycaemia.
🇮🇳 India notes
- Reported inpatient DKA mortality in India has been as high as 30% in some series, mostly due to late presentation and infection. Ketosis-prone type 2 diabetes is common.
References
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Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.