Diabetic ketoacidosis
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Look out for this icon: for treatment options that are affected, or added, as a result of your patient's comorbidities.
initial systolic blood pressure <90 mmHg
intravenous fluids and potassium replacement
Start intravenous fluids as soon as DKA is confirmed.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
Give a fluid bolus of 500 mL of normal saline (0.9% sodium chloride) over 10 to 15 minutes.
Repeat the fluid bolus if systolic blood pressure (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.
Consider other causes of hypotension (e.g., sepsis, heart failure, acute myocardial infarction).[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Give 1 L of normal saline over 1 hour once SBP >90 mmHg.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Give more cautious intravenous fluids and consider monitoring central venous pressure in patients who:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
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.
Add potassium to the second litre of intravenous fluids using pre-mixed normal saline with potassium chloride. Involve senior or critical care support as a high dose of additional potassium needs to be given.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
A typical fluid regimen for a 70 kg, well adult is:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
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 10% glucose in addition to normal saline if the glucose level falls below 14.0 mmol/L.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [47]Evans K. Diabetic ketoacidosis: update on management. Clin Med (Lond). 2019 Sep;19(5):396-8. https://www.doi.org/10.7861/clinmed.2019-0284 http://www.ncbi.nlm.nih.gov/pubmed/31530688?tool=bestpractice.com
Continue this until the patient is eating and drinking normally.
supportive care and referral to critical care
Treatment recommended for ALL patients in selected patient group
Protect the airway.
Insert a nasogastric tube and aspirate if the patient is unresponsive to commands or is persistently vomiting.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
Ensure continuous cardiac monitoring and involve senior or critical care support if:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com
There is persistent hypotension (systolic blood pressure <90 mmHg) or oliguria (urine output <0.5 mL/kg/hour) despite intravenous fluids
Glasgow Coma Scale <12 [ Glasgow Coma Scale Opens in new window ]
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 Opens in new window ]
The patient is pregnant or has heart or kidney failure or other serious comorbidities.
Insert a urinary catheter if there is incontinence or no urine is passed after 1 hour of starting treatment.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
insulin
Treatment recommended for ALL patients in selected patient group
Start a fixed-rate intravenous insulin infusion (FRIII) at a dose of 0.1 units/kg/hour or according to local protocols; continue FRIII until DKA has resolved.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17 [47]Evans K. Diabetic ketoacidosis: update on management. Clin Med (Lond). 2019 Sep;19(5):396-8. https://www.doi.org/10.7861/clinmed.2019-0284 http://www.ncbi.nlm.nih.gov/pubmed/31530688?tool=bestpractice.com Continue long-acting basal insulin if the patient is already taking this.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
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]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [53]Gosmanov AR, Gosmanova EO, Dillard-Cannon E. Management of adult diabetic ketoacidosis. Diabetes Metab Syndr Obes. 2014 Jun 30;7:255-64. http://www.ncbi.nlm.nih.gov/pubmed/25061324?tool=bestpractice.com
Use the following table as a guide:
Weight in kg | Insulin dose per hour (units) |
---|---|
60-69 | 6 |
70-79 | 7 |
80-89 | 8 |
90-99 | 9 |
100-109 | 10 |
110-119 | 11 |
120-129 | 12 |
130-139 | 13 |
140-149 | 14 |
>150 | 15 |
If the blood glucose falls below 14.0 mmol/L, consider reducing insulin dose rate.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf See monitor biochemical markers below for more information.
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]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [60]Kitabchi AE, Wall BM. Management of diabetic ketoacidosis. Am Fam Physician. 1999 Aug;60(2):455-64. http://www.ncbi.nlm.nih.gov/pubmed/10465221?tool=bestpractice.com
Continue intravenous insulin for 30 to 60 minutes after administering subcutaneous insulin to prevent relapse of DKA.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Continue intravenous fluids if the patient is not eating and drinking.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com
Start a variable rate intravenous insulin infusion (VRIII) for these patients if DKA has resolved.
Measure blood glucose regularly.
Primary options
insulin neutral: consult local protocols for dosing guidelines
These drug options and doses relate to a patient with no comorbidities.
Primary options
insulin neutral: consult local protocols for dosing guidelines
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
insulin neutral
identify and treat any precipitating acute illness
Treatment recommended for ALL patients in selected patient group
Common causes of DKA are myocardial infarction, sepsis, and pancreatitis.[30]Nair S, Yadav D, Pitchumoni CS. Association of diabetic ketoacidosis and acute pancreatitis: observations in 100 consecutive episodes of DKA. Am J Gastroenterol. 2000 Oct;95(10):2795-800. http://www.ncbi.nlm.nih.gov/pubmed/11051350?tool=bestpractice.com [47]Evans K. Diabetic ketoacidosis: update on management. Clin Med (Lond). 2019 Sep;19(5):396-8. https://www.doi.org/10.7861/clinmed.2019-0284 http://www.ncbi.nlm.nih.gov/pubmed/31530688?tool=bestpractice.com
monitor biochemical markers
Treatment recommended for ALL patients in selected patient group
Monitor biochemical markers as follows:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
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.
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]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
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 by 1 unit/hour (if there is no insulin pump malfunction) until the target rates for ketones, glucose, and bicarbonate are achieved.
If the blood glucose falls to <14.0 mmol/L:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Add 10% glucose. Give this concurrently with normal saline to correct the dehydration[47]Evans K. Diabetic ketoacidosis: update on management. Clin Med (Lond). 2019 Sep;19(5):396-8. https://www.doi.org/10.7861/clinmed.2019-0284 http://www.ncbi.nlm.nih.gov/pubmed/31530688?tool=bestpractice.com
Consider reducing the rate of intravenous insulin infusion to 0.05 units/kg/hour to avoid the risk of developing hypoglycaemia and hypokalaemia.
Evidence: Reduction of insulin rate when glucose concentrations drop to <14.0 mmol/L
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 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 previous JBDS-IP recommendations.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [132]Dhatariya KK, Nunney I, Higgins K, et al. National survey of the management of diabetic ketoacidosis (DKA) in the UK in 2014. Diabet Med. 2016 Feb;33(2):252-60. http://www.ncbi.nlm.nih.gov/pubmed/26286235?tool=bestpractice.com
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 Diabetes Association 2009 consensus statement, recommend considering reducing the rate of intravenous insulin infusion when the glucose level falls.[1]Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2009 Jul;32(7):1335-43. http://care.diabetesjournals.org/content/32/7/1335.full http://www.ncbi.nlm.nih.gov/pubmed/19564476?tool=bestpractice.com [2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
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%).[133]Al Hanshi S, Shann F. Insulin infused at 0.05 versus 0.1 units/kg/hr in children admitted to intensive care with diabetic ketoacidosis. Pediatr Crit Care Med. 2011 Mar;12(2):137-40. http://www.ncbi.nlm.nih.gov/pubmed/20473242?tool=bestpractice.com [134]Nallasamy K, Jayashree M, Singhi S, et al. Low-dose vs standard-dose insulin in pediatric diabetic ketoacidosis: a randomized clinical trial. JAMA Pediatr. 2014 Nov;168(11):999-1005. https://jamanetwork.com/journals/jamapediatrics/fullarticle/1909800 http://www.ncbi.nlm.nih.gov/pubmed/25264948?tool=bestpractice.com
A subsequent RCT also in children (n=60) had similar results.[135]Rameshkumar R, Satheesh P, Jain P, et al. Low-dose (0.05 unit/kg/hour) vs standard-dose (0.1 unit/kg/hour) insulin in the management of pediatric diabetic ketoacidosis: a randomized double-blind controlled trial. Indian Pediatr. 2021 Jul 15;58(7):617-23. https://www.indianpediatrics.net/july2021/617.pdf http://www.ncbi.nlm.nih.gov/pubmed/33612484?tool=bestpractice.com
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]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [3]British Society for Paediatric Endocrinology and Diabetes. BSPED interim guideline for the management of children and young people under the age of 18 years with diabetic ketoacidosis. April 2020 [internet publication]. https://www.bsped.org.uk/media/1798/bsped-dka-guideline-2020.pdf
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]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Assess for resolution of DKA. This is defined as:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Venous pH >7.3 AND
Blood ketone level <0.6 mmol/L AND
Bicarbonate >15 mmol/L
The Joint British Diabetes Societies for Inpatient Care guideline advises that the fixed-rate intravenous insulin infusion (FRIII) should be continued until bicarbonate is >18 mmol/L.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
monitor and treat complications
Treatment recommended for ALL patients in selected patient group
Monitor for complications regularly throughout treatment of DKA.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
Assess Glasgow Coma Scale hourly to monitor for cerebral oedema.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [ Glasgow Coma Scale Opens in new window ]
If you suspect cerebral oedema, seek immediate senior and critical care support.
Give mannitol.[61]Meaden CW, Kushner BJ, Barnes S. A rare and lethal complication: cerebral edema in the adult patient with diabetic ketoacidosis. Case Rep Emerg Med. 2018 Mar 21;2018:5043752. https://www.doi.org/10.1155/2018/5043752 http://www.ncbi.nlm.nih.gov/pubmed/29755797?tool=bestpractice.com
Consider ordering a CT head if the Glasgow Coma Scale score is deteriorating or the patient has a new or worsening headache.[136]Dixon AN, Jude EB, Banerjee AK, et al. Simultaneous pulmonary and cerebral oedema, and multiple CNS infarctions as complications of diabetic ketoacidosis: a case report. Diabet Med. 2006 May;23(5):571-3. http://www.ncbi.nlm.nih.gov/pubmed/16681567?tool=bestpractice.com
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.
sodium bicarbonate
Additional treatment recommended for SOME patients in selected patient group
Only consider giving bicarbonate if venous pH <6.9 and after discussion with a senior consultant. Monitor the patient in a critical care environment.[130]Hsieh HC, Wu SH, Chiu CC, et al. Excessive sodium bicarbonate infusion may result in osmotic demyelination syndrome during treatment of diabetic ketoacidosis: a case report. Diabetes Ther. 2019 Apr;10(2):765-71. https://www.doi.org/10.1007/s13300-019-0592-8 http://www.ncbi.nlm.nih.gov/pubmed/30843157?tool=bestpractice.com
thromboprophylaxis
Additional treatment recommended for SOME patients in selected patient group
Consider thromboprophylaxis in patients with impaired consciousness, unless it is contraindicated.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17 See our topic VTE prophylaxis.
intravenous fluids and potassium replacement
Start intravenous fluids as soon as DKA is confirmed.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
Give a fluid bolus of 500 mL of normal saline (0.9% sodium chloride) over 10 to 15 minutes.
Repeat the fluid bolus if systolic blood pressure (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.
Consider other causes of hypotension (e.g., sepsis, heart failure, acute myocardial infarction).[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Give 1 L of normal saline over 1 hour once SBP >90 mmHg.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Give more cautious intravenous fluids and consider monitoring central venous pressure in patients who:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
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.
Add 40 mmol/L potassium to the second litre of intravenous fluids using pre-mixed normal saline with potassium chloride.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
A typical fluid regimen for a 70 kg, well adult is:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
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 10% glucose in addition to normal saline if the glucose level falls below 14.0 mmol/L.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [47]Evans K. Diabetic ketoacidosis: update on management. Clin Med (Lond). 2019 Sep;19(5):396-8. https://www.doi.org/10.7861/clinmed.2019-0284 http://www.ncbi.nlm.nih.gov/pubmed/31530688?tool=bestpractice.com
Continue this until the patient is eating and drinking normally.
supportive care and referral to critical care
Additional treatment recommended for SOME patients in selected patient group
Protect the airway.
Insert a nasogastric tube and aspirate if the patient is unresponsive to commands or is persistently vomiting.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
Ensure continuous cardiac monitoring and involve senior or critical care support if:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com
There is persistent hypotension (systolic blood pressure <90 mmHg) or oliguria (urine output <0.5 mL/kg/hour) despite intravenous fluids
Glasgow Coma Scale <12 [ Glasgow Coma Scale Opens in new window ]
Blood ketones >6 mmol/L
Venous bicarbonate <5 mmol/L
Venous pH <7.0
Oxygen saturations <92% on air
Pulse >100 bpm or <60 bpm
Anion gap >16 [ Anion Gap Opens in new window ]
The patient is pregnant or has heart or kidney failure or other serious comorbidities.
Insert a urinary catheter if there is incontinence or no urine is passed after 1 hour of starting treatment.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
insulin
Treatment recommended for ALL patients in selected patient group
Start a fixed-rate intravenous insulin infusion (FRIII) at a dose of 0.1 units/kg/hour or according to local protocols; continue FRIII until DKA has resolved.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17 [47]Evans K. Diabetic ketoacidosis: update on management. Clin Med (Lond). 2019 Sep;19(5):396-8. https://www.doi.org/10.7861/clinmed.2019-0284 http://www.ncbi.nlm.nih.gov/pubmed/31530688?tool=bestpractice.com Continue long-acting basal insulin if the patient is already taking this.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
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]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [53]Gosmanov AR, Gosmanova EO, Dillard-Cannon E. Management of adult diabetic ketoacidosis. Diabetes Metab Syndr Obes. 2014 Jun 30;7:255-64. http://www.ncbi.nlm.nih.gov/pubmed/25061324?tool=bestpractice.com
Use the following table as a guide:
Weight in kg | Insulin dose per hour (units) |
---|---|
60-69 | 6 |
70-79 | 7 |
80-89 | 8 |
90-99 | 9 |
100-109 | 10 |
110-119 | 11 |
120-129 | 12 |
130-139 | 13 |
140-149 | 14 |
>150 | 15 |
If the blood glucose falls below 14.0 mmol/L, consider reducing insulin dose rate.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf See monitor biochemical markers below for more information.
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]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [60]Kitabchi AE, Wall BM. Management of diabetic ketoacidosis. Am Fam Physician. 1999 Aug;60(2):455-64. http://www.ncbi.nlm.nih.gov/pubmed/10465221?tool=bestpractice.com
Continue intravenous insulin for 30 to 60 minutes after administering subcutaneous insulin to prevent relapse of DKA.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Continue intravenous fluids if the patient is not eating and drinking.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com
Start a variable rate intravenous insulin infusion (VRIII) for these patients if DKA has resolved.
Measure blood glucose regularly.
Primary options
insulin neutral: consult local protocols for dosing guidelines
These drug options and doses relate to a patient with no comorbidities.
Primary options
insulin neutral: consult local protocols for dosing guidelines
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
insulin neutral
identify and treat any precipitating acute illness
Treatment recommended for ALL patients in selected patient group
Common causes of DKA are myocardial infarction, sepsis, and pancreatitis.[30]Nair S, Yadav D, Pitchumoni CS. Association of diabetic ketoacidosis and acute pancreatitis: observations in 100 consecutive episodes of DKA. Am J Gastroenterol. 2000 Oct;95(10):2795-800. http://www.ncbi.nlm.nih.gov/pubmed/11051350?tool=bestpractice.com [47]Evans K. Diabetic ketoacidosis: update on management. Clin Med (Lond). 2019 Sep;19(5):396-8. https://www.doi.org/10.7861/clinmed.2019-0284 http://www.ncbi.nlm.nih.gov/pubmed/31530688?tool=bestpractice.com
monitor biochemical markers
Treatment recommended for ALL patients in selected patient group
Monitor biochemical markers as follows:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
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.
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]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
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 by 1 unit/hour (if there is no insulin pump malfunction) until the target rates for ketones, glucose, and bicarbonate are achieved.
If the blood glucose falls to <14.0 mmol/L:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Add 10% glucose. Give this concurrently with normal saline to correct the dehydration[47]Evans K. Diabetic ketoacidosis: update on management. Clin Med (Lond). 2019 Sep;19(5):396-8. https://www.doi.org/10.7861/clinmed.2019-0284 http://www.ncbi.nlm.nih.gov/pubmed/31530688?tool=bestpractice.com
Consider reducing the rate of intravenous insulin infusion to 0.05 units/kg/hour to avoid the risk of developing hypoglycaemia and hypokalaemia.
Evidence: Reduction of insulin rate when glucose concentrations drop to <14.0 mmol/L
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 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 previous JBDS-IP recommendations.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [132]Dhatariya KK, Nunney I, Higgins K, et al. National survey of the management of diabetic ketoacidosis (DKA) in the UK in 2014. Diabet Med. 2016 Feb;33(2):252-60. http://www.ncbi.nlm.nih.gov/pubmed/26286235?tool=bestpractice.com
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 Diabetes Association 2009 consensus statement, recommend considering reducing the rate of intravenous insulin infusion when the glucose level falls.[1]Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2009 Jul;32(7):1335-43. http://care.diabetesjournals.org/content/32/7/1335.full http://www.ncbi.nlm.nih.gov/pubmed/19564476?tool=bestpractice.com [2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
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%).[133]Al Hanshi S, Shann F. Insulin infused at 0.05 versus 0.1 units/kg/hr in children admitted to intensive care with diabetic ketoacidosis. Pediatr Crit Care Med. 2011 Mar;12(2):137-40. http://www.ncbi.nlm.nih.gov/pubmed/20473242?tool=bestpractice.com [134]Nallasamy K, Jayashree M, Singhi S, et al. Low-dose vs standard-dose insulin in pediatric diabetic ketoacidosis: a randomized clinical trial. JAMA Pediatr. 2014 Nov;168(11):999-1005. https://jamanetwork.com/journals/jamapediatrics/fullarticle/1909800 http://www.ncbi.nlm.nih.gov/pubmed/25264948?tool=bestpractice.com
A subsequent RCT also in children (n=60) had similar results.[135]Rameshkumar R, Satheesh P, Jain P, et al. Low-dose (0.05 unit/kg/hour) vs standard-dose (0.1 unit/kg/hour) insulin in the management of pediatric diabetic ketoacidosis: a randomized double-blind controlled trial. Indian Pediatr. 2021 Jul 15;58(7):617-23. https://www.indianpediatrics.net/july2021/617.pdf http://www.ncbi.nlm.nih.gov/pubmed/33612484?tool=bestpractice.com
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]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [3]British Society for Paediatric Endocrinology and Diabetes. BSPED interim guideline for the management of children and young people under the age of 18 years with diabetic ketoacidosis. April 2020 [internet publication]. https://www.bsped.org.uk/media/1798/bsped-dka-guideline-2020.pdf
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]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Assess for resolution of DKA. This is defined as:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Venous pH >7.3 AND
Blood ketone level <0.6 mmol/L AND
Bicarbonate >15 mmol/L
The Joint British Diabetes Societies for Inpatient Care guideline advises that the fixed-rate intravenous insulin infusion should be continued until bicarbonate is >18 mmol/L.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
monitor and treat complications
Treatment recommended for ALL patients in selected patient group
Monitor for complications regularly throughout treatment of DKA.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
Assess Glasgow Coma Scale hourly to monitor for cerebral oedema.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [ Glasgow Coma Scale Opens in new window ]
If you suspect cerebral oedema, seek immediate senior and critical care support.
Give mannitol.[61]Meaden CW, Kushner BJ, Barnes S. A rare and lethal complication: cerebral edema in the adult patient with diabetic ketoacidosis. Case Rep Emerg Med. 2018 Mar 21;2018:5043752. https://www.doi.org/10.1155/2018/5043752 http://www.ncbi.nlm.nih.gov/pubmed/29755797?tool=bestpractice.com
Consider ordering a CT head if the Glasgow Coma Scale score is deteriorating or the patient has a new or worsening headache.[136]Dixon AN, Jude EB, Banerjee AK, et al. Simultaneous pulmonary and cerebral oedema, and multiple CNS infarctions as complications of diabetic ketoacidosis: a case report. Diabet Med. 2006 May;23(5):571-3. http://www.ncbi.nlm.nih.gov/pubmed/16681567?tool=bestpractice.com
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.
sodium bicarbonate
Additional treatment recommended for SOME patients in selected patient group
Only consider giving bicarbonate if venous pH <6.9 and after discussion with a senior consultant. Monitor the patient in a critical care environment.[130]Hsieh HC, Wu SH, Chiu CC, et al. Excessive sodium bicarbonate infusion may result in osmotic demyelination syndrome during treatment of diabetic ketoacidosis: a case report. Diabetes Ther. 2019 Apr;10(2):765-71. https://www.doi.org/10.1007/s13300-019-0592-8 http://www.ncbi.nlm.nih.gov/pubmed/30843157?tool=bestpractice.com
thromboprophylaxis
Additional treatment recommended for SOME patients in selected patient group
Consider thromboprophylaxis in patients with impaired consciousness, unless it is contraindicated.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17 See our topic VTE prophylaxis.
intravenous fluids
Start intravenous fluids as soon as DKA is confirmed.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
Give a fluid bolus of 500 mL of normal saline (0.9% sodium chloride) over 10 to 15 minutes.
Repeat the fluid bolus if systolic blood pressure (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.
Consider other causes of hypotension (e.g., sepsis, heart failure, acute myocardial infarction).[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Give 1 L of normal saline over 1 hour once SBP >90 mmHg.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Give more cautious intravenous fluids and consider monitoring central venous pressure in patients who:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
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.
Give ongoing fluid replacement after the first litre of fluid has been given. Do not add potassium chloride until potassium is ≤5.5 mmol/L.
A typical fluid regimen for a 70 kg, well adult is:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
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 10% glucose in addition to normal saline if the glucose level falls below 14.0 mmol/L.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [47]Evans K. Diabetic ketoacidosis: update on management. Clin Med (Lond). 2019 Sep;19(5):396-8. https://www.doi.org/10.7861/clinmed.2019-0284 http://www.ncbi.nlm.nih.gov/pubmed/31530688?tool=bestpractice.com
Continue this until the patient is eating and drinking normally.
supportive care and referral to critical care
Additional treatment recommended for SOME patients in selected patient group
Protect the airway.
Insert a nasogastric tube and aspirate if the patient is unresponsive to commands or is persistently vomiting.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
Ensure continuous cardiac monitoring and involve senior or critical care support if:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
There is persistent hypotension (systolic blood pressure <90 mmHg) or oliguria (urine output <0.5 mL/kg/hour) despite intravenous fluids
Glasgow Coma Scale <12 [ Glasgow Coma Scale Opens in new window ]
Blood ketones >6 mmol/L
Venous bicarbonate <5 mmol/L
Venous pH <7.0
Oxygen saturations <92% on air
Pulse >100 bpm or <60 bpm
Anion gap >16 [ Anion Gap Opens in new window ]
The patient is pregnant or has heart or kidney failure or other serious comorbidities.
Insert a urinary catheter if there is incontinence or no urine is passed after 1 hour of starting treatment.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
insulin
Treatment recommended for ALL patients in selected patient group
Start a fixed-rate intravenous insulin infusion (FRIII) at a dose of 0.1 units/kg/hour or according to local protocols; continue FRIII until DKA has resolved.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17 [47]Evans K. Diabetic ketoacidosis: update on management. Clin Med (Lond). 2019 Sep;19(5):396-8. https://www.doi.org/10.7861/clinmed.2019-0284 http://www.ncbi.nlm.nih.gov/pubmed/31530688?tool=bestpractice.com Continue long-acting basal insulin if the patient is already taking this.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
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]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [53]Gosmanov AR, Gosmanova EO, Dillard-Cannon E. Management of adult diabetic ketoacidosis. Diabetes Metab Syndr Obes. 2014 Jun 30;7:255-64. http://www.ncbi.nlm.nih.gov/pubmed/25061324?tool=bestpractice.com
Use the following table as a guide:
Weight in kg | Insulin dose per hour (units) |
---|---|
60-69 | 6 |
70-79 | 7 |
80-89 | 8 |
90-99 | 9 |
100-109 | 10 |
110-119 | 11 |
120-129 | 12 |
130-139 | 13 |
140-149 | 14 |
>150 | 15 |
If the blood glucose falls below 14.0 mmol/L, consider reducing insulin dose rate.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf See monitor biochemical markers below for more information.
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]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [60]Kitabchi AE, Wall BM. Management of diabetic ketoacidosis. Am Fam Physician. 1999 Aug;60(2):455-64. http://www.ncbi.nlm.nih.gov/pubmed/10465221?tool=bestpractice.com
Continue intravenous insulin for 30 to 60 minutes after administering subcutaneous insulin to prevent relapse of DKA.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Continue intravenous fluids if the patient is not eating and drinking.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com
Start a variable rate intravenous insulin infusion (VRIII) for these patients if DKA has resolved.
Measure blood glucose regularly.
Primary options
insulin neutral: consult local protocols for dosing guidelines
These drug options and doses relate to a patient with no comorbidities.
Primary options
insulin neutral: consult local protocols for dosing guidelines
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
insulin neutral
identify and treat any precipitating acute illness
Treatment recommended for ALL patients in selected patient group
Common causes of DKA are myocardial infarction, sepsis, and pancreatitis.[30]Nair S, Yadav D, Pitchumoni CS. Association of diabetic ketoacidosis and acute pancreatitis: observations in 100 consecutive episodes of DKA. Am J Gastroenterol. 2000 Oct;95(10):2795-800. http://www.ncbi.nlm.nih.gov/pubmed/11051350?tool=bestpractice.com [47]Evans K. Diabetic ketoacidosis: update on management. Clin Med (Lond). 2019 Sep;19(5):396-8. https://www.doi.org/10.7861/clinmed.2019-0284 http://www.ncbi.nlm.nih.gov/pubmed/31530688?tool=bestpractice.com
monitor biochemical markers
Treatment recommended for ALL patients in selected patient group
Monitor biochemical markers as follows:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
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.
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]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
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 by 1 unit/hour (if there is no insulin pump malfunction) until the target rates for ketones, glucose, and bicarbonate are achieved.
If the blood glucose falls to <14.0 mmol/L:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Add 10% glucose. Give this concurrently with normal saline to correct the dehydration[47]Evans K. Diabetic ketoacidosis: update on management. Clin Med (Lond). 2019 Sep;19(5):396-8. https://www.doi.org/10.7861/clinmed.2019-0284 http://www.ncbi.nlm.nih.gov/pubmed/31530688?tool=bestpractice.com
Consider reducing the rate of intravenous insulin infusion to 0.05 units/kg/hour to avoid the risk of developing hypoglycaemia and hypokalaemia.
Evidence: Reduction of insulin rate when glucose concentrations drop to <14.0 mmol/L
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 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 previous JBDS-IP recommendations.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [132]Dhatariya KK, Nunney I, Higgins K, et al. National survey of the management of diabetic ketoacidosis (DKA) in the UK in 2014. Diabet Med. 2016 Feb;33(2):252-60. http://www.ncbi.nlm.nih.gov/pubmed/26286235?tool=bestpractice.com
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 Diabetes Association 2009 consensus statement, recommend considering reducing the rate of intravenous insulin infusion when the glucose level falls.[1]Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2009 Jul;32(7):1335-43. http://care.diabetesjournals.org/content/32/7/1335.full http://www.ncbi.nlm.nih.gov/pubmed/19564476?tool=bestpractice.com [2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
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%).[133]Al Hanshi S, Shann F. Insulin infused at 0.05 versus 0.1 units/kg/hr in children admitted to intensive care with diabetic ketoacidosis. Pediatr Crit Care Med. 2011 Mar;12(2):137-40. http://www.ncbi.nlm.nih.gov/pubmed/20473242?tool=bestpractice.com [134]Nallasamy K, Jayashree M, Singhi S, et al. Low-dose vs standard-dose insulin in pediatric diabetic ketoacidosis: a randomized clinical trial. JAMA Pediatr. 2014 Nov;168(11):999-1005. https://jamanetwork.com/journals/jamapediatrics/fullarticle/1909800 http://www.ncbi.nlm.nih.gov/pubmed/25264948?tool=bestpractice.com
A subsequent RCT also in children (n=60) had similar results.[135]Rameshkumar R, Satheesh P, Jain P, et al. Low-dose (0.05 unit/kg/hour) vs standard-dose (0.1 unit/kg/hour) insulin in the management of pediatric diabetic ketoacidosis: a randomized double-blind controlled trial. Indian Pediatr. 2021 Jul 15;58(7):617-23. https://www.indianpediatrics.net/july2021/617.pdf http://www.ncbi.nlm.nih.gov/pubmed/33612484?tool=bestpractice.com
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]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [3]British Society for Paediatric Endocrinology and Diabetes. BSPED interim guideline for the management of children and young people under the age of 18 years with diabetic ketoacidosis. April 2020 [internet publication]. https://www.bsped.org.uk/media/1798/bsped-dka-guideline-2020.pdf
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]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Assess for resolution of DKA. This is defined as:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Venous pH >7.3 AND
Blood ketone level <0.6 mmol/L AND
Bicarbonate >15 mmol/L
The Joint British Diabetes Societies for Inpatient Care guideline advises that the fixed-rate intravenous insulin infusion (FRIII) should be continued until bicarbonate is >18 mmol/L.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Plus – potassium replacement (once serum potassium is ≤5.5 mmol/L)
potassium replacement (once serum potassium is ≤5.5 mmol/L)
Treatment recommended for ALL patients in selected patient group
Add potassium to intravenous fluids once serum potassium is ≤5.5 mmol/L using pre-mixed normal saline with potassium chloride.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
monitor and treat complications
Treatment recommended for ALL patients in selected patient group
Monitor for complications regularly throughout treatment of DKA.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
Assess Glasgow Coma Scale hourly to monitor for cerebral oedema.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [ Glasgow Coma Scale Opens in new window ]
If you suspect cerebral oedema, seek immediate senior and critical care support.
Give mannitol.[61]Meaden CW, Kushner BJ, Barnes S. A rare and lethal complication: cerebral edema in the adult patient with diabetic ketoacidosis. Case Rep Emerg Med. 2018 Mar 21;2018:5043752. https://www.doi.org/10.1155/2018/5043752 http://www.ncbi.nlm.nih.gov/pubmed/29755797?tool=bestpractice.com
Consider ordering a CT head if the Glasgow Coma Scale score is deteriorating or the patient has a new or worsening headache.[136]Dixon AN, Jude EB, Banerjee AK, et al. Simultaneous pulmonary and cerebral oedema, and multiple CNS infarctions as complications of diabetic ketoacidosis: a case report. Diabet Med. 2006 May;23(5):571-3. http://www.ncbi.nlm.nih.gov/pubmed/16681567?tool=bestpractice.com
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.
sodium bicarbonate
Additional treatment recommended for SOME patients in selected patient group
Only consider giving bicarbonate if venous pH <6.9 and after discussion with a senior consultant. Monitor the patient in a critical care environment.[130]Hsieh HC, Wu SH, Chiu CC, et al. Excessive sodium bicarbonate infusion may result in osmotic demyelination syndrome during treatment of diabetic ketoacidosis: a case report. Diabetes Ther. 2019 Apr;10(2):765-71. https://www.doi.org/10.1007/s13300-019-0592-8 http://www.ncbi.nlm.nih.gov/pubmed/30843157?tool=bestpractice.com
thromboprophylaxis
Additional treatment recommended for SOME patients in selected patient group
Consider thromboprophylaxis in patients with impaired consciousness, unless it is contraindicated.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17 See our topic VTE prophylaxis.
initial systolic blood pressure ≥90 mmHg
intravenous fluids and potassium replacement
Start intravenous fluids as soon as DKA is confirmed.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
Give 1 L of normal saline (0.9% sodium chloride) over 1 hour.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Give more cautious intravenous fluids and consider monitoring central venous pressure in patients who:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
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.
Add potassium to the second litre of intravenous fluids using pre-mixed normal saline with potassium chloride. Involve senior or critical care support as a high dose of additional potassium needs to be given.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
A typical fluid regimen for a 70 kg, well adult is:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
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 10% glucose in addition to normal saline if the glucose level falls below 14.0 mmol/L.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [47]Evans K. Diabetic ketoacidosis: update on management. Clin Med (Lond). 2019 Sep;19(5):396-8. https://www.doi.org/10.7861/clinmed.2019-0284 http://www.ncbi.nlm.nih.gov/pubmed/31530688?tool=bestpractice.com
Continue this until the patient is eating and drinking normally.
supportive care and referral to critical care
Treatment recommended for ALL patients in selected patient group
Protect the airway.
Insert a nasogastric tube and aspirate if the patient is unresponsive to commands or is persistently vomiting.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
Ensure continuous cardiac monitoring and involve senior or critical care support if:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com
There is persistent hypotension (systolic blood pressure <90 mmHg) or oliguria (urine output <0.5 mL/kg/hour) despite intravenous fluids
Glasgow Coma Scale <12 [ Glasgow Coma Scale Opens in new window ]
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 Opens in new window ]
The patient is pregnant or has heart or kidney failure or other serious comorbidities.
Insert a urinary catheter if there is incontinence or no urine is passed after 1 hour of starting treatment.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
insulin
Treatment recommended for ALL patients in selected patient group
Start a fixed-rate intravenous insulin infusion (FRIII) at a dose of 0.1 units/kg/hour or according to local protocols; continue FRIII until DKA has resolved.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17 [47]Evans K. Diabetic ketoacidosis: update on management. Clin Med (Lond). 2019 Sep;19(5):396-8. https://www.doi.org/10.7861/clinmed.2019-0284 http://www.ncbi.nlm.nih.gov/pubmed/31530688?tool=bestpractice.com Continue long-acting basal insulin if the patient is already taking this.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
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]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [53]Gosmanov AR, Gosmanova EO, Dillard-Cannon E. Management of adult diabetic ketoacidosis. Diabetes Metab Syndr Obes. 2014 Jun 30;7:255-64. http://www.ncbi.nlm.nih.gov/pubmed/25061324?tool=bestpractice.com
Use the following table as a guide:
Weight in kg | Insulin dose per hour (units) |
---|---|
60-69 | 6 |
70-79 | 7 |
80-89 | 8 |
90-99 | 9 |
100-109 | 10 |
110-119 | 11 |
120-129 | 12 |
130-139 | 13 |
140-149 | 14 |
>150 | 15 |
If the blood glucose falls below 14.0 mmol/L, consider reducing insulin dose rate.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf See monitor biochemical markers below for more information.
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]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [60]Kitabchi AE, Wall BM. Management of diabetic ketoacidosis. Am Fam Physician. 1999 Aug;60(2):455-64. http://www.ncbi.nlm.nih.gov/pubmed/10465221?tool=bestpractice.com
Continue intravenous insulin for 30 to 60 minutes after administering subcutaneous insulin to prevent relapse of DKA.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Continue intravenous fluids if the patient is not eating and drinking.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com
Start a variable rate intravenous insulin infusion (VRIII) for these patients if DKA has resolved.
Measure blood glucose regularly.
Primary options
insulin neutral: consult local protocols for dosing guidelines
These drug options and doses relate to a patient with no comorbidities.
Primary options
insulin neutral: consult local protocols for dosing guidelines
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
insulin neutral
identify and treat any precipitating acute illness
Treatment recommended for ALL patients in selected patient group
Common causes of DKA are myocardial infarction, sepsis, and pancreatitis.[30]Nair S, Yadav D, Pitchumoni CS. Association of diabetic ketoacidosis and acute pancreatitis: observations in 100 consecutive episodes of DKA. Am J Gastroenterol. 2000 Oct;95(10):2795-800. http://www.ncbi.nlm.nih.gov/pubmed/11051350?tool=bestpractice.com [47]Evans K. Diabetic ketoacidosis: update on management. Clin Med (Lond). 2019 Sep;19(5):396-8. https://www.doi.org/10.7861/clinmed.2019-0284 http://www.ncbi.nlm.nih.gov/pubmed/31530688?tool=bestpractice.com
monitor biochemical markers
Treatment recommended for ALL patients in selected patient group
Monitor biochemical markers as follows:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
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.
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]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
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 by 1 unit/hour (if there is no insulin pump malfunction) until the target rates for ketones, glucose, and bicarbonate are achieved.
If the blood glucose falls to <14.0 mmol/L:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Add 10% glucose. Give this concurrently with normal saline to correct the dehydration[47]Evans K. Diabetic ketoacidosis: update on management. Clin Med (Lond). 2019 Sep;19(5):396-8. https://www.doi.org/10.7861/clinmed.2019-0284 http://www.ncbi.nlm.nih.gov/pubmed/31530688?tool=bestpractice.com
Consider reducing the rate of intravenous insulin infusion to 0.05 units/kg/hour to avoid the risk of developing hypoglycaemia and hypokalaemia.
Evidence: Reduction of insulin rate when glucose concentrations drop to <14.0 mmol/L
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 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 previous JBDS-IP recommendations.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [132]Dhatariya KK, Nunney I, Higgins K, et al. National survey of the management of diabetic ketoacidosis (DKA) in the UK in 2014. Diabet Med. 2016 Feb;33(2):252-60. http://www.ncbi.nlm.nih.gov/pubmed/26286235?tool=bestpractice.com
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 Diabetes Association 2009 consensus statement, recommend considering reducing the rate of intravenous insulin infusion when the glucose level falls.[1]Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2009 Jul;32(7):1335-43. http://care.diabetesjournals.org/content/32/7/1335.full http://www.ncbi.nlm.nih.gov/pubmed/19564476?tool=bestpractice.com [2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
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%).[133]Al Hanshi S, Shann F. Insulin infused at 0.05 versus 0.1 units/kg/hr in children admitted to intensive care with diabetic ketoacidosis. Pediatr Crit Care Med. 2011 Mar;12(2):137-40. http://www.ncbi.nlm.nih.gov/pubmed/20473242?tool=bestpractice.com [134]Nallasamy K, Jayashree M, Singhi S, et al. Low-dose vs standard-dose insulin in pediatric diabetic ketoacidosis: a randomized clinical trial. JAMA Pediatr. 2014 Nov;168(11):999-1005. https://jamanetwork.com/journals/jamapediatrics/fullarticle/1909800 http://www.ncbi.nlm.nih.gov/pubmed/25264948?tool=bestpractice.com
A subsequent RCT also in children (n=60) had similar results.[135]Rameshkumar R, Satheesh P, Jain P, et al. Low-dose (0.05 unit/kg/hour) vs standard-dose (0.1 unit/kg/hour) insulin in the management of pediatric diabetic ketoacidosis: a randomized double-blind controlled trial. Indian Pediatr. 2021 Jul 15;58(7):617-23. https://www.indianpediatrics.net/july2021/617.pdf http://www.ncbi.nlm.nih.gov/pubmed/33612484?tool=bestpractice.com
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]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [3]British Society for Paediatric Endocrinology and Diabetes. BSPED interim guideline for the management of children and young people under the age of 18 years with diabetic ketoacidosis. April 2020 [internet publication]. https://www.bsped.org.uk/media/1798/bsped-dka-guideline-2020.pdf
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]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Assess for resolution of DKA. This is defined as:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Venous pH >7.3 AND
Blood ketone level <0.6 mmol/L AND
Bicarbonate >15 mmol/L
The Joint British Diabetes Societies for Inpatient Care guideline advises that the fixed-rate intravenous insulin infusion (FRIII) should be continued until bicarbonate is >18 mmol/L.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
monitor and treat complications
Treatment recommended for ALL patients in selected patient group
Monitor for complications regularly throughout treatment of DKA.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
Assess Glasgow Coma Scale hourly to monitor for cerebral oedema.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [ Glasgow Coma Scale Opens in new window ]
If you suspect cerebral oedema, seek immediate senior and critical care support.
Give mannitol.[61]Meaden CW, Kushner BJ, Barnes S. A rare and lethal complication: cerebral edema in the adult patient with diabetic ketoacidosis. Case Rep Emerg Med. 2018 Mar 21;2018:5043752. https://www.doi.org/10.1155/2018/5043752 http://www.ncbi.nlm.nih.gov/pubmed/29755797?tool=bestpractice.com
Consider ordering a CT head if the Glasgow Coma Scale score is deteriorating or the patient has a new or worsening headache.[136]Dixon AN, Jude EB, Banerjee AK, et al. Simultaneous pulmonary and cerebral oedema, and multiple CNS infarctions as complications of diabetic ketoacidosis: a case report. Diabet Med. 2006 May;23(5):571-3. http://www.ncbi.nlm.nih.gov/pubmed/16681567?tool=bestpractice.com
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.
sodium bicarbonate
Additional treatment recommended for SOME patients in selected patient group
Only consider giving bicarbonate if venous pH <6.9 and after discussion with a senior consultant. Monitor the patient in a critical care environment.[130]Hsieh HC, Wu SH, Chiu CC, et al. Excessive sodium bicarbonate infusion may result in osmotic demyelination syndrome during treatment of diabetic ketoacidosis: a case report. Diabetes Ther. 2019 Apr;10(2):765-71. https://www.doi.org/10.1007/s13300-019-0592-8 http://www.ncbi.nlm.nih.gov/pubmed/30843157?tool=bestpractice.com
thromboprophylaxis
Additional treatment recommended for SOME patients in selected patient group
Consider thromboprophylaxis in patients with impaired consciousness, unless it is contraindicated.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17 See our topic VTE prophylaxis.
intravenous fluids and potassium replacement
Start intravenous fluids as soon as DKA is confirmed.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
Give 1 L of normal saline (0.9% sodium chloride) over 1 hour.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Give more cautious intravenous fluids and consider monitoring central venous pressure in patients who:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
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.
Add 40 mmol/L potassium to the second litre of intravenous fluids using pre-mixed normal saline with potassium chloride.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
A typical fluid regimen for a 70 kg, well adult is:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
Volume of normal saline (with potassium chloride as needed) |
---|
1 litre over 2 hours |
1 litre over next 2 hours |
1 litreover next 4 hours |
1 litre over next 4 hours |
1 litre over next 6 hours |
Give 10% glucose in addition to normal saline if the glucose level falls below 14.0 mmol/L.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [47]Evans K. Diabetic ketoacidosis: update on management. Clin Med (Lond). 2019 Sep;19(5):396-8. https://www.doi.org/10.7861/clinmed.2019-0284 http://www.ncbi.nlm.nih.gov/pubmed/31530688?tool=bestpractice.com
Continue this until the patient is eating and drinking normally.
supportive care and referral to critical care
Additional treatment recommended for SOME patients in selected patient group
Protect the airway.
Insert a nasogastric tube and aspirate if the patient is unresponsive to commands or is persistently vomiting.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
Ensure continuous cardiac monitoring and involve senior or critical care support if:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com
There is persistent hypotension (systolic blood pressure <90 mmHg) or oliguria (urine output <0.5 mL/kg/hour) despite intravenous fluids
Glasgow Coma Scale <12 [ Glasgow Coma Scale Opens in new window ]
Blood ketones >6 mmol/L
Venous bicarbonate <5 mmol/L
Venous pH <7.0
Oxygen saturations <92% on air
Pulse >100 bpm or <60 bpm
Anion gap >16 [ Anion Gap Opens in new window ]
The patient is pregnant or has heart or kidney failure or other serious comorbidities.
Insert a urinary catheter if there is incontinence or no urine is passed after 1 hour of starting treatment.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
insulin
Treatment recommended for ALL patients in selected patient group
Start a fixed-rate intravenous insulin infusion (FRIII) at a dose of 0.1 units/kg/hour or according to local protocols; continue FRIII until DKA has resolved.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17 [47]Evans K. Diabetic ketoacidosis: update on management. Clin Med (Lond). 2019 Sep;19(5):396-8. https://www.doi.org/10.7861/clinmed.2019-0284 http://www.ncbi.nlm.nih.gov/pubmed/31530688?tool=bestpractice.com Continue long-acting basal insulin if the patient is already taking this.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
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]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [53]Gosmanov AR, Gosmanova EO, Dillard-Cannon E. Management of adult diabetic ketoacidosis. Diabetes Metab Syndr Obes. 2014 Jun 30;7:255-64. http://www.ncbi.nlm.nih.gov/pubmed/25061324?tool=bestpractice.com
Use the following table as a guide:
Weight in kg | Insulin dose per hour (units) |
---|---|
60-69 | 6 |
70-79 | 7 |
80-89 | 8 |
90-99 | 9 |
100-109 | 10 |
110-119 | 11 |
120-129 | 12 |
130-139 | 13 |
140-149 | 14 |
>150 | 15 |
If the blood glucose falls below 14.0 mmol/L, consider reducing insulin dose rate.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf See monitor biochemical markers below for more information.
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]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [60]Kitabchi AE, Wall BM. Management of diabetic ketoacidosis. Am Fam Physician. 1999 Aug;60(2):455-64. http://www.ncbi.nlm.nih.gov/pubmed/10465221?tool=bestpractice.com
Continue intravenous insulin for 30 to 60 minutes after administering subcutaneous insulin to prevent relapse of DKA.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Continue intravenous fluids if the patient is not eating and drinking.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com
Start a variable rate intravenous insulin infusion (VRIII) for these patients if DKA has resolved.
Measure blood glucose regularly.
Primary options
insulin neutral: consult local protocols for dosing guidelines
These drug options and doses relate to a patient with no comorbidities.
Primary options
insulin neutral: consult local protocols for dosing guidelines
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
insulin neutral
identify and treat any precipitating acute illness
Treatment recommended for ALL patients in selected patient group
Common causes of DKA are myocardial infarction, sepsis, and pancreatitis.[30]Nair S, Yadav D, Pitchumoni CS. Association of diabetic ketoacidosis and acute pancreatitis: observations in 100 consecutive episodes of DKA. Am J Gastroenterol. 2000 Oct;95(10):2795-800. http://www.ncbi.nlm.nih.gov/pubmed/11051350?tool=bestpractice.com [47]Evans K. Diabetic ketoacidosis: update on management. Clin Med (Lond). 2019 Sep;19(5):396-8. https://www.doi.org/10.7861/clinmed.2019-0284 http://www.ncbi.nlm.nih.gov/pubmed/31530688?tool=bestpractice.com
monitor biochemical markers
Treatment recommended for ALL patients in selected patient group
Monitor biochemical markers as follows:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
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.
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]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
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 by 1 unit/hour (if there is no insulin pump malfunction) until the target rates for ketones, glucose, and bicarbonate are achieved.
If the blood glucose falls to <14.0 mmol/L:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Add 10% glucose. Give this concurrently with normal saline to correct the dehydration[47]Evans K. Diabetic ketoacidosis: update on management. Clin Med (Lond). 2019 Sep;19(5):396-8. https://www.doi.org/10.7861/clinmed.2019-0284 http://www.ncbi.nlm.nih.gov/pubmed/31530688?tool=bestpractice.com
Consider reducing the rate of intravenous insulin infusion to 0.05 units/kg/hour to avoid the risk of developing hypoglycaemia and hypokalaemia.
Evidence: Reduction of insulin rate when glucose concentrations drop to <14.0 mmol/L
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 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 previous JBDS-IP recommendations.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [132]Dhatariya KK, Nunney I, Higgins K, et al. National survey of the management of diabetic ketoacidosis (DKA) in the UK in 2014. Diabet Med. 2016 Feb;33(2):252-60. http://www.ncbi.nlm.nih.gov/pubmed/26286235?tool=bestpractice.com
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 Diabetes Association 2009 consensus statement, recommend considering reducing the rate of intravenous insulin infusion when the glucose level falls.[1]Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2009 Jul;32(7):1335-43. http://care.diabetesjournals.org/content/32/7/1335.full http://www.ncbi.nlm.nih.gov/pubmed/19564476?tool=bestpractice.com [2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
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%).[133]Al Hanshi S, Shann F. Insulin infused at 0.05 versus 0.1 units/kg/hr in children admitted to intensive care with diabetic ketoacidosis. Pediatr Crit Care Med. 2011 Mar;12(2):137-40. http://www.ncbi.nlm.nih.gov/pubmed/20473242?tool=bestpractice.com [134]Nallasamy K, Jayashree M, Singhi S, et al. Low-dose vs standard-dose insulin in pediatric diabetic ketoacidosis: a randomized clinical trial. JAMA Pediatr. 2014 Nov;168(11):999-1005. https://jamanetwork.com/journals/jamapediatrics/fullarticle/1909800 http://www.ncbi.nlm.nih.gov/pubmed/25264948?tool=bestpractice.com
A subsequent RCT also in children (n=60) had similar results.[135]Rameshkumar R, Satheesh P, Jain P, et al. Low-dose (0.05 unit/kg/hour) vs standard-dose (0.1 unit/kg/hour) insulin in the management of pediatric diabetic ketoacidosis: a randomized double-blind controlled trial. Indian Pediatr. 2021 Jul 15;58(7):617-23. https://www.indianpediatrics.net/july2021/617.pdf http://www.ncbi.nlm.nih.gov/pubmed/33612484?tool=bestpractice.com
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]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [3]British Society for Paediatric Endocrinology and Diabetes. BSPED interim guideline for the management of children and young people under the age of 18 years with diabetic ketoacidosis. April 2020 [internet publication]. https://www.bsped.org.uk/media/1798/bsped-dka-guideline-2020.pdf
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]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Assess for resolution of DKA. This is defined as:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Venous pH >7.3 AND
Blood ketone level <0.6 mmol/L AND
Bicarbonate >15 mmol/L
The Joint British Diabetes Societies for Inpatient Care guideline advises that the fixed-rate intravenous insulin infusion (FRIII) should be continued until bicarbonate is >18 mmol/L.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
monitor and treat complications
Treatment recommended for ALL patients in selected patient group
Monitor for complications regularly throughout treatment of DKA.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
Assess Glasgow Coma Scale hourly to monitor for cerebral oedema.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [ Glasgow Coma Scale Opens in new window ]
If you suspect cerebral oedema, seek immediate senior and critical care support.
Give mannitol.[61]Meaden CW, Kushner BJ, Barnes S. A rare and lethal complication: cerebral edema in the adult patient with diabetic ketoacidosis. Case Rep Emerg Med. 2018 Mar 21;2018:5043752. https://www.doi.org/10.1155/2018/5043752 http://www.ncbi.nlm.nih.gov/pubmed/29755797?tool=bestpractice.com
Consider ordering a CT head if the Glasgow Coma Scale score is deteriorating or the patient has a new or worsening headache.[136]Dixon AN, Jude EB, Banerjee AK, et al. Simultaneous pulmonary and cerebral oedema, and multiple CNS infarctions as complications of diabetic ketoacidosis: a case report. Diabet Med. 2006 May;23(5):571-3. http://www.ncbi.nlm.nih.gov/pubmed/16681567?tool=bestpractice.com
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.
sodium bicarbonate
Additional treatment recommended for SOME patients in selected patient group
Only consider giving bicarbonate if venous pH <6.9 and after discussion with a senior consultant. Monitor the patient in a critical care environment.[130]Hsieh HC, Wu SH, Chiu CC, et al. Excessive sodium bicarbonate infusion may result in osmotic demyelination syndrome during treatment of diabetic ketoacidosis: a case report. Diabetes Ther. 2019 Apr;10(2):765-71. https://www.doi.org/10.1007/s13300-019-0592-8 http://www.ncbi.nlm.nih.gov/pubmed/30843157?tool=bestpractice.com
thromboprophylaxis
Additional treatment recommended for SOME patients in selected patient group
Consider thromboprophylaxis in patients with impaired consciousness, unless it is contraindicated.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17 See our topic VTE prophylaxis.
intravenous fluids
Start intravenous fluids as soon as DKA is confirmed.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
Give 1 L of normal saline (0.9% sodium chloride) over 1 hour.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Give more cautious intravenous fluids and consider monitoring central venous pressure in patients who:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
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.
Give ongoing fluid replacement after the first litre of fluid has been given. Do not add potassium chloride until potassium is ≤5.5 mmol/L.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
A typical fluid regimen for a 70 kg, well adult is:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
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 10% glucose in addition to normal saline if the glucose level falls below 14.0 mmol/L.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [47]Evans K. Diabetic ketoacidosis: update on management. Clin Med (Lond). 2019 Sep;19(5):396-8. https://www.doi.org/10.7861/clinmed.2019-0284 http://www.ncbi.nlm.nih.gov/pubmed/31530688?tool=bestpractice.com
Continue this until the patient is eating and drinking normally.
supportive care and referral to critical care
Additional treatment recommended for SOME patients in selected patient group
Protect the airway.
Insert a nasogastric tube and aspirate if the patient is unresponsive to commands or is persistently vomiting.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
Ensure continuous cardiac monitoring and involve senior or critical care support if:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
There is persistent hypotension (systolic blood pressure <90 mmHg) or oliguria (urine output <0.5 mL/kg/hour) despite intravenous fluids
Glasgow Coma Scale <12 [ Glasgow Coma Scale Opens in new window ]
Blood ketones >6 mmol/L
Venous bicarbonate <5 mmol/L
Venous pH <7.0
Oxygen saturations <92% on air
Pulse >100 bpm or <60 bpm
Anion gap >16 [ Anion Gap Opens in new window ]
The patient is pregnant or has heart or kidney failure or other serious comorbidities.
Insert a urinary catheter if there is incontinence or no urine is passed after 1 hour of starting treatment.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
insulin
Treatment recommended for ALL patients in selected patient group
Start a fixed-rate intravenous insulin infusion (FRIII) at a dose of 0.1 units/kg/hour or according to local protocols; continue FRIII until DKA has resolved.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17 [47]Evans K. Diabetic ketoacidosis: update on management. Clin Med (Lond). 2019 Sep;19(5):396-8. https://www.doi.org/10.7861/clinmed.2019-0284 http://www.ncbi.nlm.nih.gov/pubmed/31530688?tool=bestpractice.com Continue long-acting basal insulin if the patient is already taking this.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
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]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [53]Gosmanov AR, Gosmanova EO, Dillard-Cannon E. Management of adult diabetic ketoacidosis. Diabetes Metab Syndr Obes. 2014 Jun 30;7:255-64. http://www.ncbi.nlm.nih.gov/pubmed/25061324?tool=bestpractice.com
Use the following table as a guide:
Weight in kg | Insulin dose per hour (units) |
---|---|
60-69 | 6 |
70-79 | 7 |
80-89 | 8 |
90-99 | 9 |
100-109 | 10 |
110-119 | 11 |
120-129 | 12 |
130-139 | 13 |
140-149 | 14 |
>150 | 15 |
If the blood glucose falls below 14.0 mmol/L, consider reducing insulin dose rate.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf See monitor biochemical markers below for more information.
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]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [60]Kitabchi AE, Wall BM. Management of diabetic ketoacidosis. Am Fam Physician. 1999 Aug;60(2):455-64. http://www.ncbi.nlm.nih.gov/pubmed/10465221?tool=bestpractice.com
Continue intravenous insulin for 30 to 60 minutes after administering subcutaneous insulin to prevent relapse of DKA.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Continue intravenous fluids if the patient is not eating and drinking.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com
Start a variable rate intravenous insulin infusion (VRIII) for these patients if DKA has resolved.
Measure blood glucose regularly.
Primary options
insulin neutral: consult local protocols for dosing guidelines
These drug options and doses relate to a patient with no comorbidities.
Primary options
insulin neutral: consult local protocols for dosing guidelines
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
insulin neutral
identify and treat any precipitating acute illness
Treatment recommended for ALL patients in selected patient group
Common causes of DKA are myocardial infarction, sepsis, and pancreatitis.[30]Nair S, Yadav D, Pitchumoni CS. Association of diabetic ketoacidosis and acute pancreatitis: observations in 100 consecutive episodes of DKA. Am J Gastroenterol. 2000 Oct;95(10):2795-800. http://www.ncbi.nlm.nih.gov/pubmed/11051350?tool=bestpractice.com [47]Evans K. Diabetic ketoacidosis: update on management. Clin Med (Lond). 2019 Sep;19(5):396-8. https://www.doi.org/10.7861/clinmed.2019-0284 http://www.ncbi.nlm.nih.gov/pubmed/31530688?tool=bestpractice.com
monitor biochemical markers
Treatment recommended for ALL patients in selected patient group
Monitor biochemical markers as follows:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
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.
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]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
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 by 1 unit/hour (if there is no insulin pump malfunction) until the target rates for ketones, glucose, and bicarbonate are achieved.
If the blood glucose falls to <14.0 mmol/L:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Add 10% glucose. Give this concurrently with normal saline to correct the dehydration[47]Evans K. Diabetic ketoacidosis: update on management. Clin Med (Lond). 2019 Sep;19(5):396-8. https://www.doi.org/10.7861/clinmed.2019-0284 http://www.ncbi.nlm.nih.gov/pubmed/31530688?tool=bestpractice.com
Consider reducing the rate of intravenous insulin infusion to 0.05 units/kg/hour to avoid the risk of developing hypoglycaemia and hypokalaemia.
Evidence: Reduction of insulin rate when glucose concentrations drop to <14.0 mmol/L
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 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 previous JBDS-IP recommendations.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [132]Dhatariya KK, Nunney I, Higgins K, et al. National survey of the management of diabetic ketoacidosis (DKA) in the UK in 2014. Diabet Med. 2016 Feb;33(2):252-60. http://www.ncbi.nlm.nih.gov/pubmed/26286235?tool=bestpractice.com
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 Diabetes Association 2009 consensus statement, recommend considering reducing the rate of intravenous insulin infusion when the glucose level falls.[1]Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2009 Jul;32(7):1335-43. http://care.diabetesjournals.org/content/32/7/1335.full http://www.ncbi.nlm.nih.gov/pubmed/19564476?tool=bestpractice.com [2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
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%).[133]Al Hanshi S, Shann F. Insulin infused at 0.05 versus 0.1 units/kg/hr in children admitted to intensive care with diabetic ketoacidosis. Pediatr Crit Care Med. 2011 Mar;12(2):137-40. http://www.ncbi.nlm.nih.gov/pubmed/20473242?tool=bestpractice.com [134]Nallasamy K, Jayashree M, Singhi S, et al. Low-dose vs standard-dose insulin in pediatric diabetic ketoacidosis: a randomized clinical trial. JAMA Pediatr. 2014 Nov;168(11):999-1005. https://jamanetwork.com/journals/jamapediatrics/fullarticle/1909800 http://www.ncbi.nlm.nih.gov/pubmed/25264948?tool=bestpractice.com
A subsequent RCT also in children (n=60) had similar results.[135]Rameshkumar R, Satheesh P, Jain P, et al. Low-dose (0.05 unit/kg/hour) vs standard-dose (0.1 unit/kg/hour) insulin in the management of pediatric diabetic ketoacidosis: a randomized double-blind controlled trial. Indian Pediatr. 2021 Jul 15;58(7):617-23. https://www.indianpediatrics.net/july2021/617.pdf http://www.ncbi.nlm.nih.gov/pubmed/33612484?tool=bestpractice.com
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]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [3]British Society for Paediatric Endocrinology and Diabetes. BSPED interim guideline for the management of children and young people under the age of 18 years with diabetic ketoacidosis. April 2020 [internet publication]. https://www.bsped.org.uk/media/1798/bsped-dka-guideline-2020.pdf
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]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Assess for resolution of DKA. This is defined as:[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Venous pH >7.3 AND
Blood ketone level <0.6 mmol/L AND
Bicarbonate >15 mmol/L
The Joint British Diabetes Societies for Inpatient Care guideline advises that the fixed-rate intravenous insulin infusion should be continued until bicarbonate is >18 mmol/L.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
Plus – potassium replacement (once serum potassium is ≤5.5 mmol/L)
potassium replacement (once serum potassium is ≤5.5 mmol/L)
Treatment recommended for ALL patients in selected patient group
Add potassium to intravenous fluids once serum potassium is ≤5.5 mmol/L using pre-mixed normal saline with potassium chloride.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
monitor and treat complications
Treatment recommended for ALL patients in selected patient group
Monitor for complications regularly throughout treatment of DKA.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17
Assess Glasgow Coma Scale hourly to monitor for cerebral oedema.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [ Glasgow Coma Scale Opens in new window ]
If you suspect cerebral oedema, seek immediate senior and critical care support.
Give mannitol.[61]Meaden CW, Kushner BJ, Barnes S. A rare and lethal complication: cerebral edema in the adult patient with diabetic ketoacidosis. Case Rep Emerg Med. 2018 Mar 21;2018:5043752. https://www.doi.org/10.1155/2018/5043752 http://www.ncbi.nlm.nih.gov/pubmed/29755797?tool=bestpractice.com
Consider ordering a CT head if the Glasgow Coma Scale score is deteriorating or the patient has a new or worsening headache.[136]Dixon AN, Jude EB, Banerjee AK, et al. Simultaneous pulmonary and cerebral oedema, and multiple CNS infarctions as complications of diabetic ketoacidosis: a case report. Diabet Med. 2006 May;23(5):571-3. http://www.ncbi.nlm.nih.gov/pubmed/16681567?tool=bestpractice.com
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.
sodium bicarbonate
Additional treatment recommended for SOME patients in selected patient group
Only consider giving bicarbonate if venous pH <6.9 and after discussion with a senior consultant. Monitor the patient in a critical care environment.[130]Hsieh HC, Wu SH, Chiu CC, et al. Excessive sodium bicarbonate infusion may result in osmotic demyelination syndrome during treatment of diabetic ketoacidosis: a case report. Diabetes Ther. 2019 Apr;10(2):765-71. https://www.doi.org/10.1007/s13300-019-0592-8 http://www.ncbi.nlm.nih.gov/pubmed/30843157?tool=bestpractice.com
thromboprophylaxis
Additional treatment recommended for SOME patients in selected patient group
Consider thromboprophylaxis in patients with impaired consciousness, unless it is contraindicated.[2]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication]. https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf [43]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication]. https://www.nice.org.uk/guidance/ng17 See our topic VTE prophylaxis.
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