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  3. Diabetic Ketoacidosis (DKA)

Diabetic Ketoacidosis (DKA)

JBDS-IP The Management of Diabetic Ketoacidosis in Adults. Last revised: Mar 2023.

Diagnosis Guidelines

All 3 of the following must be present:
 
Component Cut-off
Diabetic-
  • Capillary blood glucose >11 mmol/L
-Keto-
  • Capillary ketone ≥3 mmol/L, or
  • Urine ketones 2+ or more
-Acidosis
  • Venous pH <7.3, and/or
  • Bicarbonate <15 mmol/L
 
 

The above-stated parameters should also be monitored regularly.

Prevention

Emphasis patients on sick-day rules:
  • NEVER stop insulin, and adjust insulin doses as instructed
  • Monitor blood glucose more frequently (every 2-4 hours)
  • Monitor ketones regularly (blood / urine) 
  • Stay hydrated and eat easily digestible carbohydrates

Acute DKA Management Guidelines

Fluid replacement to rehydrate the patient is the FIRST PRIORITY in DKA management to restore circulatory volume and stabilise the patient. Although not the definitive management, it alone will not resolve DKA. Insulin is the definitive treatment, but fluids should always be given first. This is important in both exams and clinical practice.

If systolic BP <90 mmHg → fluid bolus (500 mL of 0.9% NaCl over 10-15 min)

Once systolic BP >90 mmHg (or >90 mmHg from the start):
  • Give 1L of 0.9% NaCl over 1 hour with NO potassium (potassium only to be considered in 2nd bag onwards - see step 3 below)

Insulin is the definitive treatment that resolves DKA. However, note that insulin is NOT the first priority in managing DKA. The first priority is always fluid resuscitation.

Insulin's main effects in treating DKA are:

  • Suppression of ketogenesis
  • Reduction of blood glucose
  • Correction of electrolyte disturbance


Commence fixed rate intravenous insulin infusion (FRIII)

  • Rate: 0.1 unit/kg/hour
  • Choice of insulin: short-acting insulin (JBDS recommends human soluble insulin - Actrapid® or Humulin S®)
  • Preparation: 50 units of insulin made up to 50 mL with 0.9 NaCl
 

  • Stop any short-acting insulin
  • Continue long-acting insulin (e.g. glargine, detemir, degludec) at usual dose and time

  • Consider reducing insulin rate to 0.05 units/kg/hour
  • Add 10% dextrose at 125 mL/hr

Continue FRIIIFixed rate intravenous insulin infusion and fluid replacement:
  • 2nd bag of fluid: 1L of 0.9% NaCl over 2 hours + potassium replacement if ≤5.5 mmol/L
  • 3rd bag of fluid: 1L of 0.9% NaCl over 2 hours + potassium replacement if ≤5.5 mmol/L
  • 4th bag of fluid: 1L of 0.9% NaCl over 4 hours + potassium replacement if ≤5.5 mmol/L
  • 5th bag of fluid: 1L of 0.9% NaCl over 4 hours + potassium replacement if ≤5.5 mmol/L
  • 6th bag of fluid: 1L of 0.9% NaCl over 6 hours + potassium replacement if ≤5.5 mmol/L
 

Potassium replacement depends on potassium levels:
  • >5.5 mmol/L → no potassium replacement needed
  • 3.5-5.5 mmol/L → 40 mmol/L of potassium infusion solution
  • <3.5 → senior review (as additional potassium required)
 
 

If the potassium delivery rate exceeds 20 mmol/hour, continuous cardiac monitoring is required.

Such that if 40 mmol/L of potassium replacement is indicated in the 2nd or 3rd bag of fluids, that corresponds to 20 mmol/hour as these fluids are 1L given over 2 hours. These patients would require cardiac monitoring.

  • Ketone ↓ at least 0.5 mmol/l/hr / bicarbonate ↑ at least 3 mmol/L/hr
  • Blood glucose ↓ at least 3 mmol/L/hr
  • Maintain serum potassium in normal ranges

 

It is more important to be aware of what parameters to look at, and what trend they should be moving (i.e. what should go up and go down, to indicate treatment is working well).

In clinical practice, these exact rates would be easily accessible, and in exams, the questions tend to assess one's concept of principle, not recalling these exact rates.

Post-DKA Resolution Guidelines

DKA should resolve by 24 hours (if not → seek senior review)

Resolution criteria:
  • Ketones <0.6 mmol/L, and
  • Venous pH >7.3

  • Convert to subcutaneous insulin
    • Only discontinue the IV insulin infusion until 30 min after subcutaneous insulin has been given
 
  • Patient should be eating and drinking

References

Author: Adams Lau
Reviewer:
Last edited: 13/08/25