Recommendations

Urgent

This topic covers management of DKA in adults.

Start intravenous fluids as soon as DKA is confirmed.[2][17][46][103] 

  • Give a fluid bolus of 500 mL of normal saline (0.9% sodium chloride) over 10 to 15 minutes if the initial systolic blood pressure (SBP) is <90 mmHg.[104]

    • Repeat the fluid bolus if SBP remains <90 mmHg and get help from a senior colleague.

    • Repeat the fluid bolus, get an immediate senior review and consider involving critical care if there is no improvement after the second fluid bolus.

  • Give 1 L of normal saline over 1 hour if the initial SBP is >90 mmHg OR if SBP is >90 mmHg after fluid resuscitation.

  • Give more cautious fluids and consider monitoring central venous pressure in patients who:

    • Are young (aged 18-25 years), elderly, or pregnant

    • Have heart or kidney failure or other serious comorbidities.

  • Add potassium to the second litre of intravenous fluid if serum potassium is ≤5.5 mmol/L using pre-mixed normal saline with potassium chloride.

Start a fixed-rate intravenous insulin infusion (FRIII) according to local protocols.[2][17][46][103] Ensure intravenous fluids have already been started before giving a FRIII.

Ensure continuous cardiac monitoring and involve senior or critical care support if:[2]

  • There is persistent hypotension (SBP <90 mmHg) or oliguria (urine output <0.5 mL/kg/hour) despite intravenous fluids

  • Glasgow Coma Scale <12 [ Glasgow Coma Scale ]

  • Blood ketones >6 mmol/L

  • Venous bicarbonate <5 mmol/L

  • Venous pH <7.0

  • Potassium <3.5 mmol/L on admission

  • Oxygen saturations <92% on air

  • Pulse >100 bpm or <60 bpm

  • Anion gap >16  [ Anion Gap ]

  • The patient is pregnant or has heart or kidney failure or other serious comorbidities.

Identify and treat any precipitating acute illness.[2]

  • Common causes are myocardial infarction, sepsis, and pancreatitis.[30][46]

Key Recommendations

Management of diabetic ketoacidosis in adults

Management of diabetic ketoacidosis 1. Intravenous fluid[Figure caption and citation for the preceding image starts]: Management of diabetic ketoacidosis 1. Intravenous fluidby BMJ Knowledge Centre [Citation ends].Management of diabetic ketoacidosis 2. Potassium[Figure caption and citation for the preceding image starts]: Management of diabetic ketoacidosis 2. PotassiumBy BMJ Knowledge Centre [Citation ends].Management of diabetic ketoacidosis 3. Insulin[Figure caption and citation for the preceding image starts]: Management of diabetic ketoacidosis 3. InsulinBy BMJ Knowledge Centre [Citation ends].Management of diabetic ketoacidosis 4. Resolution[Figure caption and citation for the preceding image starts]: Management of diabetic ketoacidosis 4. ResolutionBy BMJ Knowledge Centre [Citation ends].

Additional management during the first hour

Protect the airway.

  • Insert a nasogastric tube and aspirate if the patient is unresponsive to commands or is persistently vomiting.[2][103]

Insert a urinary catheter if there is incontinence or no urine is passed after 1 hour of starting treatment.[2][103]

Give a dose of long-acting insulin to prevent rebound hyperglycaemia when DKA has resolved and the FRIII is stopped.

  • Continue long-acting basal insulin if the patient is already taking this.[2]

  • If this is the first presentation of diabetes, start a long-acting basal insulin as soon as possible.

Involve the specialist diabetes team as soon as possible and definitely within 24 hours.[2]

Ongoing management

Give ongoing fluid replacement once the first litre of fluid has been given. Add potassium if serum potassium is ≤5.5 using pre-mixed normal saline (0.9% sodium chloride) with potassium chloride.[17][103]

  • A typical regimen for a 70 kg patient with no other comorbidities is:[2][103]

Volume of normal saline (with potassium chloride as needed)

1 litre over 2 hours

1 litre over next 2 hours

1 litre over next 4 hours

1 litre over next 4 hours

1 litre over next 6 hours

Continue the FRIII. If the blood glucose falls to <14.0 mmol/L:[2][17][103]

  • Add 10% glucose. Give this concurrently with normal saline to correct the dehydration[46]

  • Consider reducing the rate of intravenous insulin infusion to 0.05 units/kg/hour to avoid the risk of developing hypoglycaemia and hypokalaemia.

Monitor biochemical parameters to ensure these are improving.[2][103]

  • Measure venous bicarbonate, potassium, pH, blood glucose, and blood ketones as follows:

Ketones

Glucose

Bicarbonate

Potassium

pH

0 hours

1 hour

2 hours

3 hours

4 hours

5 hours

6 hours

12 hours

Aim for a reduction in blood ketones of 0.5 mmol/L/hour if blood ketone measurement is available.[2]

  • Use venous bicarbonate or blood glucose if blood ketone measurement is unavailable. Aim for an increase in venous bicarbonate of 3.0 mmol/L/hour or a reduction in blood glucose of 3.0 mmol/L/hour.

  • Increase the FRIII according to local protocols if these targets are not met.

Monitor for cerebral and pulmonary oedema.[2]

  • Assess Glasgow Coma Scale hourly.

  • Order a chest x-ray if oxygen saturations fall and consider performing an arterial blood gas.


Radial artery puncture animated demonstrationRadial artery puncture animated demonstration

Femoral artery puncture animated demonstrationFemoral artery puncture animated demonstration

Resolution of DKA

Involve senior or specialist input if DKA has not resolved within 24 hours. Resolution of DKA is defined as:[2]

  • Venous pH >7.3 AND

  • Blood ketone level <0.6 mmol/L AND

  • Bicarbonate >15 mmol/L

    • The 2021 Joint British Diabetes Societies for Inpatient Care guideline advises that the FRIII should be continued until bicarbonate is >18 mmol/L.[2]

Switch to subcutaneous insulin once DKA has resolved and the patient is eating and drinking. This should normally be done by the specialist diabetes team.[2]

  • Start subcutaneous insulin with a meal and continue the FRIII for 30 to 60 minutes after this.

Continue intravenous fluids and switch to a variable rate intravenous insulin infusion (VRIII) if DKA is resolved but the patient is not eating and drinking.[2]

Discharge

Ensure the patient has been reviewed by the diabetes specialist team before discharge and has follow up.[2]

Counsel patients about causes and early warning symptoms of DKA. Provide access to psychological support.

Full recommendations

Treatment should aim to:[2]

  • Restore circulatory volume[46]

  • Suppress ketogenesis[46]

  • Correct electrolyte imbalance[46]

  • Normalise blood glucose

  • Treat the precipitating cause and prevent complications.

Practical tip

This topic covers DKA in adults. Bear in mind that people aged 16 to 18 years may be managed by either a paediatric team or an adult medical team according to local arrangements. The 2021 Joint British Diabetes Societies for Inpatient Care guideline recommends following paediatric guidelines if the patient is being managed by a paediatric team, and following adult guidance if they are being managed by an adult team.[2][3]

In the UK, the British Society for Paediatric Endocrinology and Diabetes publishes guidance for the management of DKA in children.[3] 

Protect the airway.

  • Insert a nasogastric tube and aspirate if the patient is unresponsive to commands or persistently vomiting.[2][103]

  • Aspiration is a common complication of DKA due to gastroparesis.[103][105]


Tracheal intubation animated demonstrationTracheal intubation animated demonstration

Bag-valve-mask ventilation animated demonstrationBag-valve-mask ventilation animated demonstration

Insert a large bore cannula and start intravenous fluids as soon as DKA is confirmed.[2][46]

  • Seek immediate help from critical care if you are unable to get intravenous access.[2]


Peripheral venous cannulation animated demonstrationPeripheral venous cannulation animated demonstration

Give a fluid bolus of 500 mL normal saline (0.9% sodium chloride) over 10 to 15 minutes if the initial SBP is <90 mmHg.[2]

  • Repeat the fluid bolus if SBP remains <90 mmHg and seek senior help.[2]

  • Repeat the fluid bolus, get an immediate senior review and consider involving critical care if there is no improvement after the second fluid bolus.

    • Consider other causes of hypotension (e.g., sepsis, heart failure, acute myocardial infarction).[2]

Practical tip

Most patients require 500 to 1000 mL of fluid rapidly on arrival.[2]

Check your local protocols for recommendations on the management of mild DKA.

Globally, there are differences in management between countries reflecting access to healthcare resources, variations in diagnostic criteria, and the lack of published evidence to guide treatment.[1][17]

In UK practice, it is likely that all patients with DKA, regardless of severity, will be admitted to hospital. Some experts suggest that hospital admission may be avoided for patients who are alert, who do not need critical care input, and who meet other pre-specified criteria (e.g., pH and bicarbonate remaining within defined thresholds).[17] They suggest that these patients are managed with oral fluids instead of intravenous fluids, and with subcutaneous rapid-acting insulin instead of intravenous insulin.[17] This does not represent usual practice in the UK. 

Give 1 L of normal saline over 1 hour once SBP >90 mmHg OR if initial SBP is >90 mmHg.[2]

  • Typical fluid deficits in DKA are:[2]

    • Water - 100 mL/kg

    • Sodium - 7 to 10 mmol/kg

    • Chloride - 3 to 5 mmol/kg

    • Potassium - 3 to 5 mmol/kg.

  • The aim of the first few litres of fluid is to:[2]

    • Correct any hypotension

    • Replenish the intravascular deficit

    • Correct any electrolyte disturbance.

Give more cautious intravenous fluids and consider monitoring central venous pressure in patients who:[2]

  • Are young (aged 18-25 years) as rapid fluid replacement may increase the risk of cerebral oedema in these patients

  • Are elderly or pregnant

  • Have heart or kidney failure or other serious comorbidities.


Central venous catheter insertion animated demonstrationCentral venous catheter insertion animated demonstration

Practical tip

Hartmann’s solution (Ringer’s lactate) is not normally used outside of critical care.[2] This is because it: 

  • Contains 29 mmol/L of lactate, which can exacerbate the high lactate to pyruvate ratio in DKA and lead to adverse outcomes[120]

  • Raises the plasma lactate, which leads to more glucose being produced[120]

  • Contains 5 mmol/L of potassium, which can lead to fatal cardiac arrhythmias such as bradycardia or asystole if the patient has hyperkalaemia on arrival[120]

  • Contains bicarbonate, which can worsen the existing metabolic acidosis[120]

  • Is a hypotonic solution. This increases the risk of cerebral oedema in patients who are hyponatraemic on arrival.[120][121][122]

There is a debate about the benefits of using normal saline (0.9% sodium chloride) over Hartmann’s solution (Ringer’s lactate) in patients with DKA, as both have advantages and disadvantages. In the UK, the 2021 Joint British Diabetes Societies for Inpatient Care (JBDS-IP) guideline recommends using normal saline for fluid resuscitation in patients with DKA on the general ward.[2]

The studies specifically discussed in this JBDS-IP guideline include the following. 

  • Two randomised controlled trials (RCTs) with small patient numbers comparing balanced electrolyte solution with normal saline were unable to show clear evidence of a difference in terms of clinical outcomes.[123][124]

  • One subsequent post-hoc analysis of two cluster RCTs suggested that balanced crystalloid may lead to faster resolution of DKA than normal saline, but not when given in a general ward (non-ICU) environment.[125] 

  • The JBDS-IP guideline authors mention a systematic review on this issue, which at the time of writing the guideline, was still in progress.[126]

Normal saline for fluid resuscitation in patients with DKA

  • Advantages:

    • Normal saline is readily available on general wards and clinicians are experienced with this product.[2]

    • Normal saline is available with pre-mixed potassium so it complies with the UK National Patient Safety Agency (NPSA) recommendations. The NPSA states that commercially prepared ready to use diluted solutions containing potassium should be used wherever possible to reduce the risk of misadministration of potassium, so normal saline is recommended in the UK.[2][127]

    • It is important to avoid the need to add concentrated potassium to resuscitation fluids, as there is a risk of death from misadministration of concentrated potassium.[128]

  • Disadvantages:

    • A potential disadvantage of normal saline is that hyperchloraemic metabolic acidosis is a possible complication, due to the large volume of sodium chloride required for fluid resuscitation in DKA.[2]

    • Hyperchloraemic metabolic acidosis may result in a delay to resolution of the acidosis because it can cause arterial vasoconstriction in the kidneys and subsequent oliguria.[2]

Hartmann’s solution (Ringer’s lactate) for fluid resuscitation in patients with DKA

  • Advantages:

    • Hartmann’s solution has a minimal tendency to cause hyperchloraemic metabolic acidosis, due to the lower chloride content than normal saline.[2]

  • Disadvantages:

    • In general, doctors in the UK are less familiar using Hartmann’s solution clinically and it is not as readily available in clinical areas.[2]

    • Hartmann’s solution contains potassium, which could be harmful in early DKA.[120]

    • However, it also does not contain enough potassium if used alone once the potassium levels begin to fall. It is also not commercially available with pre-mixed potassium and therefore it does not comply with UK NPSA recommendations.[2]

    • Hartmann’s solution can further increase the lactate to pyruvate ratio, which is raised in DKA, worsen acidosis due to the bicarbonate content, and worsen cerebral oedema as it is hypotonic.[120]

Add potassium to the second litre of intravenous fluids if serum potassium is ≤5.5 mmol/L using pre-mixed normal saline with potassium chloride. Replace according to the potassium level on a venous blood gas as follows:[2][103]

Potassium level (mmol/L)

Potassium replacement (mmol/L of infusion solution)

<3.5

Involve senior or critical care support as additional potassium needs to be given

3.5 to 5.5

40

>5.5

None

Use normal saline with pre-mixed potassium chloride as the default fluid for resuscitation in DKA.

  • Manually adding potassium to intravenous fluids in general clinical areas is unsafe as this can result in accidental overdose of potassium, which can be fatal.[127]

  • Hyperkalaemia and hypokalaemia are life-threatening complications and common in DKA.[2][17]

    • These can precipitate life-threatening cardiac arrhythmias.

    • Serum potassium is often high on admission (although total body potassium is low).

Start a FRIII according to local protocols.[2][17][46][103] 

  • Ensure intravenous fluids have been started before giving a FRIII.

  • Seek advice from the diabetes specialist team if >15 units/hour of insulin are required.[2][52]

Practical tip

  • Only give an intramuscular bolus of insulin if there is a delay in setting up a FRIII.[2]

  • Write out ‘units’ when prescribing insulin. Never use abbreviations such as ‘U’ or ‘IU’.[2]

  • Estimate the patient’s weight if necessary.[2]

  • If the patient is pregnant, use the current pregnancy weight and call for immediate senior obstetric help.[2]

  • Avoid rapid correction of hyperglycaemia as this increases the risk of cerebral oedema.[59]

Ensure continuous cardiac monitoring and involve senior or critical care support if:[2]

  • There is persistent hypotension (SBP <90 mmHg) or oliguria (urine output <0.5 mL/kg/hour) despite intravenous fluids

  • Glasgow Coma Scale <12  [ Glasgow Coma Scale ]

  • Blood ketones >6 mmol/L

  • Venous bicarbonate <5 mmol/L

  • Venous pH <7.0

  • Potassium < 3.5 mmol/L on admission

  • Oxygen saturations <92% on air

  • Pulse >100 bpm or <60 bpm

  • Anion gap >16  [ Anion Gap ]

  • The patient is pregnant or has heart or kidney failure or other serious comorbidities.

    • DKA in pregnancy can result in significant morbidity and mortality for both the mother and the fetus.[67]

Consider giving bicarbonate only if venous pH <6.9 and after discussion with a senior consultant. Monitor the patient in a critical care environment.[129]

  • Bicarbonate has been associated with the development of cerebral oedema.[129]

The UK 2021 Joint British Diabetes Societies for Inpatient Care (JBDS-IP) guideline on management of DKA does not recommend routine use of intravenous bicarbonate for DKA in adults, stating that acidosis will resolve with adequate fluid and insulin therapy.[2]

The JBDS-IP 2021 guideline cites a systematic review that reported data from 44 studies of bicarbonate treatment for severe acidaemia in patients with DKA, including three randomised controlled trials (RCTs) in adults (total number: 73 adults).[130]

  • Two of the included RCTs in adults showed transient improvement in metabolic acidosis with bicarbonate within the initial 2 hours, but no evidence of improved glycaemic control or clinical efficacy.[130]

  • It found no studies reporting on cerebral oedema in adults or on patients with an admission pH <6.85.[130]

    • Retrospective studies in children receiving bicarbonate for DKA have found an increased risk of cerebral oedema and prolonged hospitalisation.[130]

Seek senior advice if your patient has severe acidosis, or if bicarbonate treatment is being considered.

Practical tip

Do not routinely replace phosphate.[2]

  • However, severe phosphate deficiency can worsen respiratory failure, precipitate cardiac arrhythmias, and cause rhabdomyolysis.[2]

  • If any of these clinical features are present, consider phosphate measurement and replacement as per local guidance.[2]

Discuss severe hypomagnesaemia with a senior; magnesium may need to be replaced but there is no guidance for cut-off values.

Insert a urinary catheter if there is incontinence or no urine is passed after 1 hour of starting treatment.[2][103]

Give a dose of long-acting insulin to prevent rebound hyperglycaemia when DKA has resolved and the FRIII is stopped.[2]

  • Continue long-acting basal insulin if the patient is already taking this.

  • If this is the first presentation of diabetes, start a long-acting basal insulin as soon as possible.

Practical tip

Never omit insulin in any patient with type 1 diabetes as this can precipitate DKA.[17]

  • In a UK survey, more than 7% of cases of DKA were in an inpatient population. It is often wrongly assumed that patients aged over 50 years have type 2 diabetes and can tolerate periods of insulin omission when admitted to hospital.

  • Continuing long-acting insulin during DKA also prevents rebound hyperglycaemia when the FRIII is stopped.[2]

Involve the specialist diabetes team as soon as possible and definitely within 24 hours.[2]

  • The specialist diabetes team should also be involved in the assessment of the cause of DKA.

  • It is unsafe to manage DKA without the specialist diabetes team and could compromise patient care.[2]

Identify and treat any precipitating acute illness.[2]

  • Common causes are myocardial infarction, sepsis, and pancreatitis.[30][46]

Consider thromboprophylaxis in patients with impaired consciousness, unless it is contraindicated.[2][103] See our topic VTE prophylaxis

Ensure effective handover of patients with DKA.

  • Give relevant details on the clinical and biochemical progress of the patient and the plan for further management.

Practical tip

Handover is a common source of error in managing DKA.

Management at 1 to 6 hours

Review the patient hourly to ensure clinical and biochemical improvement and continue the FRIII.[2][103]

  • Order hourly blood glucose and hourly blood ketones.

  • Perform a venous blood gas for pH, bicarbonate, and potassium at 60 minutes, 2 hours, and 2 hourly thereafter.

    • Aim for a reduction in blood ketones of 0.5 mmol/L/hour if blood ketone measurement is available.

    • Use venous bicarbonate or blood glucose measurement if blood ketone measurement is not available.

      • Aim for an increase in venous bicarbonate of 3.0 mmol/L/hour or a reduction in blood glucose of 3.0 mmol/L/hour.

    • If the target rates for blood ketones, blood glucose, and venous bicarbonate are not achieved:[2]

      • Check the insulin infusion pump is working and connected and that the correct insulin residual volume is present (to check for pump malfunction)

      • Increase the insulin infusion according to local protocols (if there is no insulin pump malfunction) until the target rates for ketones, glucose, and bicarbonate are achieved.

Practical tip

Monitor all patients with DKA closely:

  • DKA is complicated to manage and needs close monitoring and treatment modifications.[17]

  • Treatment protocols are often not followed.[17] However, guidelines and protocols should not replace sound clinical judgement.[17]

Give ongoing fluid replacement after the first litre of fluid has been given. Add potassium if serum potassium is ≤5.5 mmol/L using pre-mixed normal saline with potassium chloride.

  • A typical regimen for a 70 kg adult with no other comorbidities is:[2][17][103]

Volume of normal saline (with potassium chloride as needed)

1 litre over 2 hours

1 litre over next 2 hours

1 litre over next 4 hours

1 litre over next 4 hours

1 litre over next 6 hours

Give more cautious intravenous fluids and consider monitoring central venous pressure in patients who:[2]

  • Are young (aged 18-25 years) as rapid fluid replacement may increase the risk of cerebral oedema in these patients

  • Are elderly or pregnant

  • Have heart or kidney failure or other serious comorbidities.


Central venous catheter insertion animated demonstrationCentral venous catheter insertion animated demonstration

Maintain an accurate fluid balance chart.[2]

  • Aim for a minimum urine output of 0.5 mL/kg/hour.

Maintain the potassium level between 4.0 and 5.0 mmol/L. Adjust potassium replacement as follows:[2]

Potassium level (mmol/L)

Potassium replacement (mmol/L of infusion solution)

<3.5

Involve senior or critical care support as additional potassium needs to be given

3.5 to 5.5

40

>5.5

None

If the glucose level falls <14.0 mmol/L:[2][46]

  • Give 10% glucose in addition to normal saline and continue until the patient is eating and drinking normally

  • Consider reducing the rate of intravenous insulin infusion to 0.05 units/kg/hour to avoid the risk of developing hypoglycaemia and hypokalaemia.

Practical tip

A common mistake is to allow hypoglycaemia to develop as the blood glucose level may drop rapidly as ketoacidosis is corrected.[2]

  • This may lead to a rebound ketosis driven by counter-regulatory hormones and lengthen the duration of treatment.

  • Severe hypoglycaemia is associated with cardiac arrhythmias, acute brain injury, and death.

It is important to give glucose and sodium chloride solutions concurrently to correct the dehydration.[2] Also consider reduction of the insulin infusion rate once the glucose level falls below 14.0 mmol/L.[2]

In people with DKA, reducing the insulin rate once blood glucose <14 mmol/L may help reduce the risk of hypoglycaemia and hyperkalaemia.

In the 2021 Joint British Diabetes Societies for Inpatient Care (JBDS-IP) guideline the panel considered the issue of hypoglycaemia and hypokalaemia, which a UK national survey had identified as a significant outcome in the management of DKA despite widespread adoption of the previous JBDS-IP recommendations.[2][131]

  • The main cause was the use of insulin.

  • Although there was an absence of trial evidence in adults with DKA the panel noted that other adult guidelines, including the American Diabetic Association 2009 consensus statement, recommend considering reducing the rate of intravenous insulin infusion when the glucose level falls.[1][2]  

  • One randomised controlled trial (RCT) in children with DKA (n=50) found that a lower rate of insulin infusion (0.05 units/kg/hour compared with 0.1 units/kg/hour) did not significantly increase the time to resolution of acidosis but fewer children on the lower dose developed hypokalaemia (20% vs. 48%) or hypoglycemia (4% vs. 20%).[132][133]

  • A subsequent RCT also in children (n=60) had similar results.[134] 

  • UK paediatric guidelines on the management of DKA recommend a starting dose of 0.05 units/kg/hour to reduce the risk of hypoglycaemia, although they note that management in children with severe DKA and adolescents may be more similar to that in adults, starting at a higher rate and reducing if required.[2][3]

Based on the other guidelines, and the indirect evidence from children, the JBDS-IP panel recommended that in adults with DKA the insulin infusion rate should be reduced to 0.05 units/kg/hour when blood glucose falls below 14 mmol/L.[2]

Monitor for complications regularly throughout treatment of DKA.[2][103]

  • Assess Glasgow Coma Scale hourly to monitor for cerebral oedema.[2]

    • If you suspect cerebral oedema, seek immediate senior and critical care support.

      • Give mannitol.[60]

      • Consider ordering a CT head if the Glasgow Coma Scale score is deteriorating or the patient has a new or worsening headache.[135]

  • Monitor vital signs closely according to local protocols.

    • Request a chest x-ray if oxygen saturations fall as this may be a sign of pulmonary oedema. Consider performing an arterial blood gas.

      • Pulmonary oedema and acute respiratory distress syndrome (ARDS) are rare but significant complications of treatment for DKA and present with fluid overload and low oxygen saturations.[136] They occur when excess fluid is given, even in patients with normal cardiac function. 

      • Look for an increased alveolar to oxygen gradient (AaO2) and auscultate for lung crepitations.

      • Pulmonary oedema and ARDS are more common in patients who are severely dehydrated or with higher glucose levels on arrival.


Radial artery puncture animated demonstrationRadial artery puncture animated demonstration

Femoral artery puncture animated demonstrationFemoral artery puncture animated demonstration

Practical tip

Other features of cerebral oedema are recurrent vomiting, incontinence, irritability, abnormal respirations, and cranial nerve dysfunction. These usually occur several hours after starting treatment.[2][59]

The exact cause of cerebral oedema is unknown. It occurs most commonly in children and adolescents, and is rare over the age of 28. It is the most common cause of mortality in DKA.[2][4][59]

Give thromboprophylaxis if indicated.[2][103]

  • See our topic VTE prophylaxis.

Management at 6 to 12 hours

Continue intravenous fluids, potassium correction, and FRIII.[2][17] Seek senior advice if clinical and biochemical markers are not improving.

  • Check ketones, blood glucose, venous pH, bicarbonate, and potassium at 6 hours.

Assess for resolution of DKA. This is defined as:[2]

  • Venous pH >7.3 AND

  • Blood ketone level <0.6 mmol/L AND

  • Bicarbonate >15 mmol/L

    • The 2021 Joint British Diabetes Societies for Inpatient Care guideline advises that the FRIII should be continued until bicarbonate is >18 mmol/L.[2]

Practical tip

Do not rely on bicarbonate alone to assess the resolution of DKA.[2][59]

  • A hyperchloraemic acidosis typically persists secondary to high volumes of normal saline. This lowers the bicarbonate and leads to difficulty in assessing whether ketosis has resolved.[2][17][59]

  • The hyperchloraemic acidosis may cause renal vasoconstriction and oliguria.

Do not rely on urinary ketone clearance to assess resolution of DKA.[2]

  • These will still be present when DKA has resolved.

Management at 12 to 24 hours

Check venous pH, bicarbonate, potassium, ketones, and glucose at 12 hours. Ensure DKA has resolved within 24 hours.[2][103]

Request senior or specialist input if DKA has not resolved within 24 hours.[2]

  • It is unusual for patients not to respond to treatment so it is important to identify and treat the cause of DKA.

  • Continue the FRIII and intravenous fluids.

  • Monitor blood ketones and glucose hourly, and pH, potassium, and bicarbonate every 2 hours to ensure they fall at the specified target rates.

Start regular subcutaneous insulin when DKA is resolved and the patient is eating and drinking. This should normally be done by the diabetes specialist team and given with a meal.[2][59]

  • Switch to subcutaneous insulin from intravenous insulin in the morning if possible as most hospitals have better staffing during daytime, should DKA recur.[105]

Continue intravenous insulin for 30 to 60 minutes after administering subcutaneous insulin to prevent relapse of DKA.[2]

  • It is a common error to stop intravenous insulin either too early or before the timing and doses of subcutaneous insulin have been sorted out.[17]

If the patient was on basal bolus insulin:[2]

  • This should have been continued if they were taking a long-acting insulin analogue[17]

  • Restart their normal short-acting subcutaneous insulin at the next meal

  • In general, restart the patient’s previous insulin regimen if their most recent HbA1c shows an acceptable level of control l (i.e., HbA1c 64 mmol/mol [<8.0%])[2]

  • Do not stop the intravenous insulin if the long-acting insulin has been stopped in error until a form of background insulin has been given.[2]

    • Give half the usual daily dose of basal insulin (using insulin isophane) in the morning if the basal analogue was normally taken once daily in the evening and the intention is to convert to subcutaneous insulin in the morning.

    • Check the blood ketone and glucose levels regularly.

If the patient was on twice daily fixed-mix insulin:[2]

  • Re-introduce the subcutaneous insulin before breakfast or before the evening meal. Do not change at any other time.

If the patient was on continuous subcutaneous insulin infusion (CSII):[2]

  • Restart the CSII at the normal basal rate

  • Continue the intravenous insulin infusion until the meal bolus has been given

  • Do not restart CSII at bedtime.

Estimate the total daily dose (TDD) of insulin for patients who were not previously taking insulin.[2]

  • Take into account the patient’s sensitivity to insulin, degree of glycaemic control, insulin resistance, and age.

  • Calculate TDD by multiplying the patient’s weight (in kg) by 0.5 to 0.75 units. For example: a person weighing 72 kg would require approximately 72 x 0.5 units (36 units) for a TDD. Use 0.75 units/kg for people thought to be more insulin resistant (e.g., adolescents, obese people).

  • If using a basal bolus regimen:

    • Give 50% of the TDD with the evening meal as long-acting insulin and divide the remaining dose equally between pre-breakfast, pre-lunch, and pre-evening meal.

    • Give the first dose of fast acting subcutaneous insulin preferably before breakfast.

      • Only give the first dose before the evening meal if monitoring is in place.

      • Never convert to a subcutaneous regimen at bed time.

  • If using a twice daily pre-mixed regimen:

    • Give two-thirds of the TDD at breakfast and give the remaining third with the evening meal.

Practical tip

Use a basal bolus regimen for most patients, especially the young and fit.

Consider a twice daily pre-mixed regimen for older patients as they may not be able to manage a basal bolus regimen.

Continue intravenous fluids if the patient is not eating and drinking.[2][17]

  • Start a variable rate intravenous insulin infusion (VRIII) for these patients if DKA has resolved.

  • Measure blood glucose regularly.

Counsel patients about the precipitating cause and early warning symptoms of DKA. Consider:[2][17]

  • Review of their usual glycaemic control

  • Review of their injection technique, blood glucose monitoring, equipment, and injection sites

  • Prevention of recurrence (e.g., provide written ‘sick day rules’)

  • Checking the patient’s insulin prior to reuse (this may be expired or denatured)

  • Assessing the need for provision of handheld ketone meters for use at home

  • Providing a contact number on how to contact the diabetes specialist team out of hours

  • Providing a written care plan which allows the patient to have an active role in their diabetes management, with a copy of this sent to their GP.

Ensure patients have appropriate follow-up with the diabetes specialist team and access to psychological support.[2]

Use of this content is subject to our disclaimer