Diabetic Ketoacidosis (DKA)
Disclaimer: This protocol is an educational reference intended to support — not replace — institutional policy, pharmacy and therapeutics review, and individual clinical judgment. Verify current dosing, contraindications, and local formulary/practice constraints before adopting into an EMR or using in patient care.
Overview
The 2024 ADA/EASD/JBDS/AACE/DTS consensus report substantially updated DKA management for the first time since 2009: diagnosis and resolution are now centered on quantitative beta-hydroxybutyrate (BHB) rather than anion gap, and mild/moderate uncomplicated DKA can be managed with subcutaneous insulin — potentially avoiding ICU admission altogether. This protocol also uses the local Basal-Bolus Insulin Calculation Tips reference for the IV-to-SQ transition step, since that dosing math is already institution-approved.
Steps
- 01
Diagnose Using the D-K-A Criteria
Table 1. DKA diagnostic criteria (all three required)
Criterion Threshold D — Diabetes Glucose ≥ 200 mg/dL, or known diabetes history K — Ketosis Beta-hydroxybutyrate ≥ 3.0 mmol/L, or urine ketones ≥ 2+ A — Acidosis pH < 7.3, or bicarbonate < 18 mmol/L Anion gap is not recommended as a first-line diagnostic criterion under the current consensus.
- 02
Classify Severity
Table 2. Severity classification
Severity Beta-HB (mmol/L) pH HCO₃ (mmol/L) Mental status Mild ≤ 6 > 7.25 ≥ 15 Normal Moderate ≤ 6 7.0–7.25 10–<15 Normal/drowsy Severe > 6 < 7.0 < 10 Stupor/coma Severity determines the insulin route in Step 5 — this is the key triage decision for ICU vs. non-ICU management.
- 03
Initial Fluid Resuscitation
- Isotonic saline or balanced crystalloid, 500–1000 mL/hour initially (absent cardiac or renal compromise, which warrants a slower rate).
- Once glucose falls below 250 mg/dL, add dextrose 5–10% to the fluid to allow continued insulin infusion without hypoglycemia.
- Adjust subsequent fluid choice/rate based on hemodynamics and serum sodium trend.
- 04
Check and Correct Potassium Before/With Insulin
Table 3. Potassium repletion thresholds
Initial K⁺ Action < 3.5 mmol/L Hold insulin. Replace at 10 mmol/hour first. 3.5–5.0 mmol/L Replace concurrently with insulin; target 4–5 mmol/L. > 5.0 mmol/L Hold replacement; recheck before starting. Recheck potassium 2 hours after starting insulin, then every 4 hours.
- 05
Start Insulin — Route Depends on Severity
- Severe DKA: Fixed-rate IV insulin infusion, 0.1 units/kg/hour (or a nurse-driven variable-rate protocol) — requires ICU-level monitoring.
- Mild/moderate, uncomplicated DKA: Subcutaneous rapid-acting insulin every 1–2 hours is an appropriate alternative and can avoid ICU admission — this is a genuine site-of-care decision, not just a route preference, and should be made explicitly with the admitting team.
- Continue insulin (IV or SQ) until ketonemia resolves, tracked by falling beta-hydroxybutyrate — not until glucose normalizes, which can happen well before ketosis clears.
- 06
Monitor
- Glucose hourly.
- Potassium at 2 hours, then every 4 hours.
- Beta-hydroxybutyrate trend to confirm resolution (or anion gap/venous pH trend if BHB is not available locally — see Adoption Notes).
- 07
Confirm Resolution
- Ketonemia resolved (BHB trending down toward normal).
- Acid-base status normalized (pH/HCO₃).
- Patient alert and tolerating oral intake.
- 08
Identify and Treat the Precipitant
Common precipitants to actively screen for: infection, new-onset diabetes, insulin non-adherence/pump failure, MI, pancreatitis, and medications — including SGLT2 inhibitors, which can cause euglycemic DKA (normal or only mildly elevated glucose despite true ketoacidosis; don't let a normal glucose delay the diagnosis in a patient on an SGLT2 inhibitor).
- 09
Transition to Subcutaneous Basal-Bolus Insulin
Using the local Basal-Bolus Insulin Calculation Tips reference:
- Total Daily Dose (TDD) = 70% of the current estimated 24-hour IV insulin infusion dose.
- Initiate basal insulin 2 hours before discontinuing the IV infusion — do not stop the drip first and start basal later.
- Split: 50% of TDD as basal (glargine daily, or detemir twice daily); 50% as meal-time bolus (rapid-acting, divided across meals) if eating, or per the continuous/bolus tube-feed or NPO schedule if not.
- Worked example: IV insulin averaging 2 units/hour × 24 h = 48 units → × 0.7 = 34 units TDD → ÷ 2 = 17 units basal + 17 units bolus (≈ 5–6 units per meal if divided across 3 meals).
- Weight-based starting alternative (if no IV infusion rate to convert from): 0.3 units/kg/day for hypoglycemia-risk patients (lean, hepatic impairment, renal/cardiac disease, elderly), 0.4 units/kg/day for no clear risk factors, 0.5–0.7 units/kg/day for obesity/insulin resistance/steroid use.
Algorithm
Scroll sideways to see the full algorithm.
EMR Order Set
- DKA order set trigger, capturing severity classification at entry.
- IV insulin infusion order (weight-based 0.1 units/kg/hr) or SQ rapid-acting insulin protocol order (mild/moderate uncomplicated pathway) — mutually exclusive selection, not both.
- Potassium replacement order, gated to the K⁺ threshold table (Step 4).
- Transition-to-SQ order, timed to start basal insulin 2 hours before the IV infusion stop order executes.
- Hourly glucose (POC).
- Potassium at 2 hours post-insulin-start, then every 4 hours.
- Beta-hydroxybutyrate trend per protocol interval (or anion gap trend if BHB unavailable).
- Strict I/O.
- Insulin infusion concentration/rate verification against weight-based dosing.
- Potassium repletion verification and renal-dosing check.
- NPO until clinically improving; carbohydrate-controlled diet consult once tolerating oral intake (per admission workflow in the local basal-bolus reference).
Build notes — severity classification and the IV-vs-SQ insulin route decision should be a structured field captured at DKA order-set entry, so ICU-avoidance rate (mild/moderate managed via SQ pathway) can be tracked as a metric.
Adoption Notes
- Confirm local BHB (point-of-care beta-hydroxybutyrate) availability before building this order set — the whole severity/resolution framework above assumes it. If unavailable, define a fallback using anion gap and venous pH/HCO₃ trend, and flag that as a known deviation from the current consensus criteria.
- The mild/moderate SQ-only pathway is a genuine site-of-care decision — align with ED/hospitalist leadership on where those patients are managed (ED observation, step-down, floor with frequent POC glucose) before building the order set, since it changes ICU utilization.
- Step 9's dosing math mirrors the hospital's existing Basal-Bolus Insulin Calculation Tips reference — coordinate with the Diabetes Program team rather than duplicating a separate numbering scheme.
Success Metrics & Monitoring
Time to ketosis resolution, ICU length of stay for DKA, hypoglycemia rate during insulin therapy, hypokalemia events, rate of appropriate SQ-only (ICU-avoidance) pathway use, and 30-day DKA readmission rate. Track via the critical care database and glycemic management program data; review monthly during rollout.
Suggested Reading
- [1]
Umpierrez GE, Davis GM, ElSayed NA, et al. Hyperglycemic Crises in Adults With Diabetes: A Consensus Report. *Diabetes Care*. 2024;47(8):1257–1275. doi:10.2337/dci24-0032. Primary current guideline — first update since 2009; introduces BHB-centered diagnosis/severity/resolution and the SQ-only pathway for mild/moderate uncomplicated DKA that this protocol is built from.
- [2]
LBMC Diabetes Program and Services. Basal-Bolus Insulin Calculation Tips (internal reference), 2024. Local, already-approved dosing reference behind this protocol's Step 9 IV-to-SQ transition math and weight-based starting doses.
Revision History
| Version | Date | Editor | Summary |
|---|---|---|---|
| 0.1 | 2026-07-19 | FunctionalHealth editorial team | Initial version; source DKA.pdf in the local folder was image-based and could not be auto-extracted, so this version is built from the 2024 ADA/EASD consensus report and the local basal-bolus insulin reference instead |
Disclaimer: This protocol is an educational reference intended to support — not replace — institutional policy, pharmacy and therapeutics review, and individual clinical judgment. Verify current dosing, contraindications, and local formulary/practice constraints before adopting into an EMR or using in patient care.