Diabetic ketoacidosis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

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

ACUTE

initial systolic blood pressure <90 mmHg

serum potassium <3.5 mmol/L

1st line – intravenous fluids and potassium replacement

Back

1st line –

intravenous fluids and potassium replacement

Start intravenous fluids as soon as DKA is confirmed.[2][17][43]

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]

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

Give more cautious intravenous fluids and consider monitoring central venous pressure in patients who:[2]
- Are young (aged 18-25 years) as rapid fluid replacement may increase the risk of cerebral oedema in these patients
- Are elderly or pregnant
- Have heart or kidney failure or other serious comorbidities.

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][43]

A typical fluid regimen for a 70 kg, well adult is:[2][17][43]

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][47]

Continue this until the patient is eating and drinking normally.

Plus – supportive care and referral to critical care

Back

Plus –

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][43]

Ensure continuous cardiac monitoring and involve senior or critical care support if:[2][17]

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][43]

Plus – insulin

Back

Plus –

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][17][43][47] Continue long-acting basal insulin if the patient is already taking this.[2]

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][53]
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] 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][60]

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

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

Start a variable rate intravenous insulin infusion (VRIII) for these patients if DKA has resolved.
Measure blood glucose regularly.

Primary options

insulin neutral: consult local protocols for dosing guidelines

Plus – identify and treat any precipitating acute illness

Plus – monitor biochemical markers

Back

Plus –

monitor biochemical markers

Treatment recommended for ALL patients in selected patient group

Monitor biochemical markers as follows:[2][43]

	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]
- 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]

Add 10% glucose. Give this concurrently with normal saline to correct the dehydration[47]
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][132]

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][2]
One randomised controlled trial (RCT) in children with DKA (n=50) found that a lower rate of insulin infusion (0.05 units/kg/hour compared with 0.1 units/kg/hour) did not significantly increase the time to resolution of acidosis but fewer children on the lower dose developed hypokalaemia (20% vs. 48%) or hypoglycemia (4% vs. 20%).[133][134]
A subsequent RCT also in children (n=60) had similar results.[135]
UK paediatric guidelines on the management of DKA recommend a starting dose of 0.05 units/kg/hour to reduce the risk of hypoglycaemia, although they note that management in children with severe DKA and adolescents may be more similar to that in adults, starting at a higher rate and reducing if required.[2][3]

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

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

Venous pH >7.3 AND
Blood ketone level <0.6 mmol/L AND
Bicarbonate >15 mmol/L
- The 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]

Plus – monitor and treat complications

Back

Plus –

monitor and treat complications

Treatment recommended for ALL patients in selected patient group

Monitor for complications regularly throughout treatment of DKA.[2][43]

Assess Glasgow Coma Scale hourly to monitor for cerebral oedema.[2] [ Glasgow Coma Scale Opens in new window ]
- If you suspect cerebral oedema, seek immediate senior and critical care support.
  - Give mannitol.[61]
  - Consider ordering a CT head if the Glasgow Coma Scale score is deteriorating or the patient has a new or worsening headache.[136]
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.

Consider – sodium bicarbonate

Consider – thromboprophylaxis

serum potassium 3.5 to 5.5 mmol/L

1st line – intravenous fluids and potassium replacement

Back

1st line –

intravenous fluids and potassium replacement

Start intravenous fluids as soon as DKA is confirmed.[2][17][43]

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]

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

Give more cautious intravenous fluids and consider monitoring central venous pressure in patients who:[2]
- Are young (aged 18-25 years) as rapid fluid replacement may increase the risk of cerebral oedema in these patients
- Are elderly or pregnant
- Have heart or kidney failure or other serious comorbidities.

Add 40 mmol/L potassium to the second litre of intravenous fluids using pre-mixed normal saline with potassium chloride.[2][43]

A typical fluid regimen for a 70 kg, well adult is:[2][17][43]

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][47]

Continue this until the patient is eating and drinking normally.

Consider – supportive care and referral to critical care

Back

Consider –

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][43]

Ensure continuous cardiac monitoring and involve senior or critical care support if:[2][17]

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][43]

Plus – insulin

Back

Plus –

insulin

Treatment recommended for ALL patients in selected patient group

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][53]
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] 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][60]

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

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

Start a variable rate intravenous insulin infusion (VRIII) for these patients if DKA has resolved.
Measure blood glucose regularly.

Primary options

insulin neutral: consult local protocols for dosing guidelines

Plus – identify and treat any precipitating acute illness

Plus – monitor biochemical markers

Back

Plus –

monitor biochemical markers

Treatment recommended for ALL patients in selected patient group

Monitor biochemical markers as follows:[2][43]

	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]
- 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]

Add 10% glucose. Give this concurrently with normal saline to correct the dehydration[47]
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.

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][2]
One randomised controlled trial (RCT) in children with DKA (n=50) found that a lower rate of insulin infusion (0.05 units/kg/hour compared with 0.1 units/kg/hour) did not significantly increase the time to resolution of acidosis but fewer children on the lower dose developed hypokalaemia (20% vs. 48%) or hypoglycemia (4% vs. 20%).[133][134]
A subsequent RCT also in children (n=60) had similar results.[135]
UK paediatric guidelines on the management of DKA recommend a starting dose of 0.05 units/kg/hour to reduce the risk of hypoglycaemia, although they note that management in children with severe DKA and adolescents may be more similar to that in adults, starting at a higher rate and reducing if required.[2][3]

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

Venous pH >7.3 AND
Blood ketone level <0.6 mmol/L AND
Bicarbonate >15 mmol/L
- The 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]

Plus – monitor and treat complications

Back

Plus –

monitor and treat complications

Treatment recommended for ALL patients in selected patient group

Monitor for complications regularly throughout treatment of DKA.[2][43]

Assess Glasgow Coma Scale hourly to monitor for cerebral oedema.[2] [ Glasgow Coma Scale Opens in new window ]
- If you suspect cerebral oedema, seek immediate senior and critical care support.
  - Give mannitol.[61]
  - Consider ordering a CT head if the Glasgow Coma Scale score is deteriorating or the patient has a new or worsening headache.[136]
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.

Consider – sodium bicarbonate

Consider – thromboprophylaxis

serum potassium >5.5 mmol/L

1st line – intravenous fluids

Back

1st line –

intravenous fluids

Start intravenous fluids as soon as DKA is confirmed.[2][17][43]

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]

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

Give more cautious intravenous fluids and consider monitoring central venous pressure in patients who:[2]
- Are young (aged 18-25 years) as rapid fluid replacement may increase the risk of cerebral oedema in these patients
- Are elderly or pregnant
- Have heart or kidney failure or other serious comorbidities.

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][17][43]

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][47]

Continue this until the patient is eating and drinking normally.

Consider – supportive care and referral to critical care

Back

Consider –

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][43]

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

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][43]

Plus – insulin

Back

Plus –

insulin

Treatment recommended for ALL patients in selected patient group

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][53]
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] 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][60]

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

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

Start a variable rate intravenous insulin infusion (VRIII) for these patients if DKA has resolved.
Measure blood glucose regularly.

Primary options

insulin neutral: consult local protocols for dosing guidelines

Plus – identify and treat any precipitating acute illness

Plus – monitor biochemical markers

Back

Plus –

monitor biochemical markers

Treatment recommended for ALL patients in selected patient group

Monitor biochemical markers as follows:[2][43]

	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]
- 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]

Add 10% glucose. Give this concurrently with normal saline to correct the dehydration[47]
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.

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][2]
One randomised controlled trial (RCT) in children with DKA (n=50) found that a lower rate of insulin infusion (0.05 units/kg/hour compared with 0.1 units/kg/hour) did not significantly increase the time to resolution of acidosis but fewer children on the lower dose developed hypokalaemia (20% vs. 48%) or hypoglycemia (4% vs. 20%).[133][134]
A subsequent RCT also in children (n=60) had similar results.[135]
UK paediatric guidelines on the management of DKA recommend a starting dose of 0.05 units/kg/hour to reduce the risk of hypoglycaemia, although they note that management in children with severe DKA and adolescents may be more similar to that in adults, starting at a higher rate and reducing if required.[2][3]

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

Venous pH >7.3 AND
Blood ketone level <0.6 mmol/L AND
Bicarbonate >15 mmol/L
- The 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]

Plus – potassium replacement (once serum potassium is ≤5.5 mmol/L)

Plus – monitor and treat complications

Back

Plus –

monitor and treat complications

Treatment recommended for ALL patients in selected patient group

Monitor for complications regularly throughout treatment of DKA.[2][43]

Assess Glasgow Coma Scale hourly to monitor for cerebral oedema.[2] [ Glasgow Coma Scale Opens in new window ]
- If you suspect cerebral oedema, seek immediate senior and critical care support.
  - Give mannitol.[61]
  - Consider ordering a CT head if the Glasgow Coma Scale score is deteriorating or the patient has a new or worsening headache.[136]
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.

Consider – sodium bicarbonate

Consider – thromboprophylaxis

initial systolic blood pressure ≥90 mmHg

serum potassium <3.5 mmol/L

1st line – intravenous fluids and potassium replacement

Back

1st line –

intravenous fluids and potassium replacement

Start intravenous fluids as soon as DKA is confirmed.[2][17][43]

Give 1 L of normal saline (0.9% sodium chloride) over 1 hour.[2]

Give more cautious intravenous fluids and consider monitoring central venous pressure in patients who:[2]
- Are young (aged 18-25 years) as rapid fluid replacement may increase the risk of cerebral oedema in these patients
- Are elderly or pregnant
- Have heart or kidney failure or other serious comorbidities.

A typical fluid regimen for a 70 kg, well adult is:[2][17][43]

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][47]

Continue this until the patient is eating and drinking normally.

Plus – supportive care and referral to critical care

Back

Plus –

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][43]

Ensure continuous cardiac monitoring and involve senior or critical care support if:[2][17]

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][43]

Plus – insulin

Back

Plus –

insulin

Treatment recommended for ALL patients in selected patient group

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][53]
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] 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][60]

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

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

Start a variable rate intravenous insulin infusion (VRIII) for these patients if DKA has resolved.
Measure blood glucose regularly.

Primary options

insulin neutral: consult local protocols for dosing guidelines

Plus – identify and treat any precipitating acute illness

Plus – monitor biochemical markers

Back

Plus –

monitor biochemical markers

Treatment recommended for ALL patients in selected patient group

Monitor biochemical markers as follows:[2][43]

	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]
- 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]

Add 10% glucose. Give this concurrently with normal saline to correct the dehydration[47]
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.

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][2]
One randomised controlled trial (RCT) in children with DKA (n=50) found that a lower rate of insulin infusion (0.05 units/kg/hour compared with 0.1 units/kg/hour) did not significantly increase the time to resolution of acidosis but fewer children on the lower dose developed hypokalaemia (20% vs. 48%) or hypoglycemia (4% vs. 20%).[133][134]
A subsequent RCT also in children (n=60) had similar results.[135]
UK paediatric guidelines on the management of DKA recommend a starting dose of 0.05 units/kg/hour to reduce the risk of hypoglycaemia, although they note that management in children with severe DKA and adolescents may be more similar to that in adults, starting at a higher rate and reducing if required.[2][3]

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

Venous pH >7.3 AND
Blood ketone level <0.6 mmol/L AND
Bicarbonate >15 mmol/L
- The 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]

Plus – monitor and treat complications

Back

Plus –

monitor and treat complications

Treatment recommended for ALL patients in selected patient group

Monitor for complications regularly throughout treatment of DKA.[2][43]

Assess Glasgow Coma Scale hourly to monitor for cerebral oedema.[2] [ Glasgow Coma Scale Opens in new window ]
- If you suspect cerebral oedema, seek immediate senior and critical care support.
  - Give mannitol.[61]
  - Consider ordering a CT head if the Glasgow Coma Scale score is deteriorating or the patient has a new or worsening headache.[136]
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.

Consider – sodium bicarbonate

Consider – thromboprophylaxis

serum potassium 3.5 to 5.5 mmol/L

1st line – intravenous fluids and potassium replacement

Back

1st line –

intravenous fluids and potassium replacement

Start intravenous fluids as soon as DKA is confirmed.[2][17][43]

Give 1 L of normal saline (0.9% sodium chloride) over 1 hour.[2]

Give more cautious intravenous fluids and consider monitoring central venous pressure in patients who:[2]
- Are young (aged 18-25 years) as rapid fluid replacement may increase the risk of cerebral oedema in these patients
- Are elderly or pregnant
- Have heart or kidney failure or other serious comorbidities.

Add 40 mmol/L potassium to the second litre of intravenous fluids using pre-mixed normal saline with potassium chloride.[2][43]

A typical fluid regimen for a 70 kg, well adult is:[2][17][43]

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][47]

Continue this until the patient is eating and drinking normally.

Consider – supportive care and referral to critical care

Back

Consider –

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][43]

Ensure continuous cardiac monitoring and involve senior or critical care support if:[2][17]

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][43]

Plus – insulin

Back

Plus –

insulin

Treatment recommended for ALL patients in selected patient group

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][53]
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] 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][60]

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

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

Start a variable rate intravenous insulin infusion (VRIII) for these patients if DKA has resolved.
Measure blood glucose regularly.

Primary options

insulin neutral: consult local protocols for dosing guidelines

Plus – identify and treat any precipitating acute illness

Plus – monitor biochemical markers

Back

Plus –

monitor biochemical markers

Treatment recommended for ALL patients in selected patient group

Monitor biochemical markers as follows:[2][43]

	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]
- 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]

Add 10% glucose. Give this concurrently with normal saline to correct the dehydration[47]
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.

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][2]
One randomised controlled trial (RCT) in children with DKA (n=50) found that a lower rate of insulin infusion (0.05 units/kg/hour compared with 0.1 units/kg/hour) did not significantly increase the time to resolution of acidosis but fewer children on the lower dose developed hypokalaemia (20% vs. 48%) or hypoglycemia (4% vs. 20%).[133][134]
A subsequent RCT also in children (n=60) had similar results.[135]
UK paediatric guidelines on the management of DKA recommend a starting dose of 0.05 units/kg/hour to reduce the risk of hypoglycaemia, although they note that management in children with severe DKA and adolescents may be more similar to that in adults, starting at a higher rate and reducing if required.[2][3]

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

Venous pH >7.3 AND
Blood ketone level <0.6 mmol/L AND
Bicarbonate >15 mmol/L
- The 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]

Plus – monitor and treat complications

Back

Plus –

monitor and treat complications

Treatment recommended for ALL patients in selected patient group

Monitor for complications regularly throughout treatment of DKA.[2][43]

Assess Glasgow Coma Scale hourly to monitor for cerebral oedema.[2] [ Glasgow Coma Scale Opens in new window ]
- If you suspect cerebral oedema, seek immediate senior and critical care support.
  - Give mannitol.[61]
  - Consider ordering a CT head if the Glasgow Coma Scale score is deteriorating or the patient has a new or worsening headache.[136]
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.

Consider – sodium bicarbonate

Consider – thromboprophylaxis

serum potassium >5.5 mmol/L

1st line – intravenous fluids

Back

1st line –

intravenous fluids

Start intravenous fluids as soon as DKA is confirmed.[2][17][43]

Give 1 L of normal saline (0.9% sodium chloride) over 1 hour.[2]

Give more cautious intravenous fluids and consider monitoring central venous pressure in patients who:[2]
- Are young (aged 18-25 years) as rapid fluid replacement may increase the risk of cerebral oedema in these patients
- Are elderly or pregnant
- Have heart or kidney failure or other serious comorbidities.

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][43]

A typical fluid regimen for a 70 kg, well adult is:[2][17][43]

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][47]

Continue this until the patient is eating and drinking normally.

Consider – supportive care and referral to critical care

Back

Consider –

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][43]

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

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][43]

Plus – insulin

Back

Plus –

insulin

Treatment recommended for ALL patients in selected patient group

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][53]
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] 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][60]

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

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

Start a variable rate intravenous insulin infusion (VRIII) for these patients if DKA has resolved.
Measure blood glucose regularly.

Primary options

insulin neutral: consult local protocols for dosing guidelines

Plus – identify and treat any precipitating acute illness

Plus – monitor biochemical markers

Back

Plus –

monitor biochemical markers

Treatment recommended for ALL patients in selected patient group

Monitor biochemical markers as follows:[2][43]

	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]
- 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]

Add 10% glucose. Give this concurrently with normal saline to correct the dehydration[47]
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.

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][2]
One randomised controlled trial (RCT) in children with DKA (n=50) found that a lower rate of insulin infusion (0.05 units/kg/hour compared with 0.1 units/kg/hour) did not significantly increase the time to resolution of acidosis but fewer children on the lower dose developed hypokalaemia (20% vs. 48%) or hypoglycemia (4% vs. 20%).[133][134]
A subsequent RCT also in children (n=60) had similar results.[135]
UK paediatric guidelines on the management of DKA recommend a starting dose of 0.05 units/kg/hour to reduce the risk of hypoglycaemia, although they note that management in children with severe DKA and adolescents may be more similar to that in adults, starting at a higher rate and reducing if required.[2][3]

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

Venous pH >7.3 AND
Blood ketone level <0.6 mmol/L AND
Bicarbonate >15 mmol/L
- The 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]

Plus – potassium replacement (once serum potassium is ≤5.5 mmol/L)

Plus – monitor and treat complications

Back

Plus –

monitor and treat complications

Treatment recommended for ALL patients in selected patient group

Monitor for complications regularly throughout treatment of DKA.[2][43]

Assess Glasgow Coma Scale hourly to monitor for cerebral oedema.[2] [ Glasgow Coma Scale Opens in new window ]
- If you suspect cerebral oedema, seek immediate senior and critical care support.
  - Give mannitol.[61]
  - Consider ordering a CT head if the Glasgow Coma Scale score is deteriorating or the patient has a new or worsening headache.[136]
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.

Consider – sodium bicarbonate

Consider – thromboprophylaxis

Use of this content is subject to our disclaimer

Diabetic ketoacidosis

Treatment algorithm

initial systolic blood pressure <90 mmHg

serum potassium <3.5 mmol/L

intravenous fluids and potassium replacement

supportive care and referral to critical care

insulin

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

identify and treat any precipitating acute illness

monitor biochemical markers

Evidence: Reduction of insulin rate when glucose concentrations drop to <14.0 mmol/L

monitor and treat complications

sodium bicarbonate

thromboprophylaxis

serum potassium 3.5 to 5.5 mmol/L

intravenous fluids and potassium replacement

supportive care and referral to critical care

insulin

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

identify and treat any precipitating acute illness

monitor biochemical markers

Evidence: Reduction of insulin rate when glucose concentrations drop to <14.0 mmol/L

monitor and treat complications

sodium bicarbonate

thromboprophylaxis

serum potassium >5.5 mmol/L

intravenous fluids

supportive care and referral to critical care

insulin

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

identify and treat any precipitating acute illness

monitor biochemical markers

Evidence: Reduction of insulin rate when glucose concentrations drop to <14.0 mmol/L

potassium replacement (once serum potassium is ≤5.5 mmol/L)

monitor and treat complications

sodium bicarbonate

thromboprophylaxis

initial systolic blood pressure ≥90 mmHg

serum potassium <3.5 mmol/L

intravenous fluids and potassium replacement

supportive care and referral to critical care

insulin

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

identify and treat any precipitating acute illness

monitor biochemical markers

Evidence: Reduction of insulin rate when glucose concentrations drop to <14.0 mmol/L

monitor and treat complications

sodium bicarbonate

thromboprophylaxis

serum potassium 3.5 to 5.5 mmol/L

intravenous fluids and potassium replacement

supportive care and referral to critical care

insulin

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

identify and treat any precipitating acute illness

monitor biochemical markers

Evidence: Reduction of insulin rate when glucose concentrations drop to <14.0 mmol/L

monitor and treat complications

sodium bicarbonate

thromboprophylaxis