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Adult Diabetic Ketoacidosis (DKA)
Treatment Guideline
Primary Diagnositic Criteria
Additional diagnostic criteria (not always present)
 Serum Glucose greater than 250mg/dL
 Arterial pH less than 7.30
 Serum bicarbonate less than 15 mMol/L
 Serum Ketone (Beta-Hydroxybutyric Acid > 2mMol/L
 Anion Gap greater than 14 (*anion gap may be
normal if albumin is low)
Calculations
■ Anion Gap (Normal 10-14 mEq/L) = ([Na+]) - ([Cl-] + [HCO3-])
■ Corrected Anion Gap (for low serum albumin) = [measured AG + (4 - albumin) x 2.5)]
■ Corrected Na+ = measured Na+ + 1.6 [serum glucose-100]
100
■ Free Water Deficit = [dosing factor (0.6 male, 0.5 female) x body weight (kg)] x [(serum Na + ÷140) -1]
Emergency Department Triage
● If blood glucose greater than 500mg/dL (or HHH) or urinalysis is dip positive for ketones ESI Triage Category
Level 2.
● Initial Stat labs: Glucose, Sodium, Potassium, Chloride, CO2, BUN, Creatinine, Magnesium, CBC w/ diff,
hepatic profile, Urinalysis and Microscopy, Serum Osmolality, Phosphorus, Albumin, Amylase, Lipase,
B-HCG (reproductive age females).
● Place two peripheral IV lines. In cases of severe electrolyte disturbance or shock, consider central venous access.

All patients diagnosed with DKA will be admitted to an ICU
1. Initiate IV Fluids STAT: IVF should be started in the ED and continued in ICU as needed
 Estimate intravascular volume status (via BUN/Cr, VS, orthostatic BP, urine output, physical exam,
HgB)to estimate saline requirement.
 Assess free water deficit using corrected serum Na.
A.
Initial Fluid Orders:
I. First correct intravascular fluid volume deficit with normal saline at a rate dependant on
severity (being more cautious if cardiac or renal disease)
a) 0.9% NaCl at 1-3 Liters /hr (15-20ml/kg) over 1 hour
b) Give additional 0.9% NaCl IV rapidly if patient remains volume depleted.
B.
While Blood Glucose greater than 250 mg/dL -- Subsequent Fluid Orders:
I. Calculate corrected Na:
a) Corrected Sodium less than 134 mEq/L: continue 0.9% NaCl IV at 250-500 ml/hr
until glucose less than 250 mg/dL, or corrected Na greater than 134 mEq/L.
b) Corrected Sodium greater than or equal to 134 mEq/L: continue with 0.45% NaCl
IV at 250-500 ml/hour until glucose less than 250 mg/dL, or corrected Na less
than 134 mEq/L.
II. If corrected Na decreases more than 2 mEq per hour, consider slowing the infusion rate.
Adult Diabetic Ketoacidosis (DKA) Treatment Guideline
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C.
WHEN Blood Glucose less than 250mg/dL -- Subsequent Fluid Orders:
I. Calculate corrected Na:
a) Corrected sodium less than134 mEq/L: D5W/0.9% NaCl IV at 100 - 200 ml/hr
b) Corrected Sodium greater than or equal to 134 mEq/L: D5W/0.45% NaCl IV at
100 - 200 ml/hr
2. Insulin Administration:
 Hold all home anti-diabetic medications.
 Initiate Insulin therapy AFTER IV fluid resuscitation has begun (500 ml or greater) and when potassium is
3.2 mEq/L or greater.
 Insulin Infusion starting dose: (See Step 1 in Insulin Infusion Protocol; Page 4)
A. Blood Glucose greater than or equal to 300mg/dL  give 0.1 units/kg IV bolus and begin insulin
infusion at 0.1 units/kg/hour, rounded to 0.5 unit increment, and use Insulin Infusion Protocol.
B.
Blood Glucose less than300mg/dL  begin insulin infusion at 0.05 units/kg/hour, rounded to 0.5
unit increment, and follow Insulin Infusion Protocol.
3. Look for DKA Precipitant

If clinically indicated consider: Cardiac Enzymes, Blood Cultures, Urine Culture, CXR, EKG Serum lactate.
4. Metabolic Monitoring
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Check POC Blood Glucose on arrival to ICU and repeat every 30-60 minutes while on continuous insulin
infusion. For detailed POC glucose monitoring see Insulin Infusion Protocol (Page 3).
Order STAT basic metabolic panel/BMP (Glucose, Sodium, Potassium, Chloride, CO2, BUN, Creatinine)
every 2-4 hours depending on disease severity and clinical response to treatment.
Calculate anion gap and corrected serum Na+ with every basic metabolic panel.
Refractory Metabolic Acidosis:
If pH less than 6.9 (due primarily to metabolic acidosis) despite at least a 1 hour infusion of insulin,
consider treatment with IV Sodium Bicarbonate.
5. Potassium (K+) Correction:
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Per UPHS formulary, maximum peripheral IV infusion rate of Potassium Chloride is 10 mEq/hr.
Maximum central IV infusion rate of Potassium Chloride is 20 mEq/hr.
If serum K+ is less than 2.8 mEq/L, consider a central line to enable Potassium Chloride infusion rates of 20
mEq/hr. Monitor K+ every 2 hours until serum K+ is greater than 2.8 mEq/L.
If serum K+ is 2.8 mEq/L or greater use table for suggested repletion regimen. Note suggested repletion
assumes normal renal function.
If oliguria or kidney injury is present, re-check K+ every 2 hours. If patient does not have oliguria or kidney
injury re-check serum K+ every 4 hours.
For patients able to tolerate clear liquids by mouth, oral K+ repletion should be considered.
Serum Potassium
Suggested Repletion Regimen
2.8 - 3.2 mEq/L
3.3 – 3.5 mEq/L
3.6 – 4.9 mEq/L
greater than 4.9 mEq/L
administer 60 mEq of Potassium Chloride IV
administer 40 mEq of Potassium Chloride IV
administer 20 mEq of Potassium Chloride IV
No repletion
Adult Diabetic Ketoacidosis (DKA) Treatment Guideline
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Diabetic Ketoacidosis (DKA) Insulin Infusion Protocol
Patient Weight = _________ kg
*Anion Gap = ([Na+] ) - ([Cl-] + [HCO3-]), as measured on a basic metabolic panel
*Correct Anion Gap for low albumin. Corrected anion gap = Measured anion gap + (4 - albumin) X 2.5
Step 1. Initial Insulin Infusion Dosing
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If Blood Glucose is greater than or equal to 300 mg/dL: Give 0.1units/kg IV insulin bolus. Start insulin infusion rate
at 0.1 units/kg/hour and round to 0.5 unit increment. (Example: weight = 70 kg, 70 x 0.10 = 7 infusion rate is 7
units/hour)
If Blood Glucose is less than 300 mg/dL: Start insulin infusion rate at 0.05 units/kg/hour and round to 0.5 unit
increment (Example: weight = 71 kg, 71 x 0.05 = 3.55 infusion rate is 3.5 units/hour)
Titrate Insulin infusion using Table 1 below. Continue to round dose to the nearest 0.5 units/hour
TARGET GOAL: drop in serum glucose is 50-100 mg/dL/hour
When Blood Glucose less than or equal to 250 mg/dL go to Step 2
Table 1 – Insulin Infusion Titration for BG greater than 250 mg/dL (NOT on D5 containing fluid)
Blood Glucose Change
decrease less than 50 mg/dL
decrease 50-100 mg/dL
decrease greater than 100 mg/dL
Insulin Infusion
Increase rate by 50% (current rate x 1.5)
Continue current rate
Decrease rate by 25% (current rate x 0.75)
POC Glucose Monitoring
Repeat blood glucose in
1 hour
Hypoglycemia Treatment
less than or equal to 80 mg/dL
 HOLD insulin infusion
 Notify MD/NP/PA
 Give 25 ml D50 IVP
 Add D5 containing fluids
 when BG > 100 mg/dL restart insulin infusion at
0.05Units/kg /hr or continue current rate if already less
than 0.05Units/kg/hr
 Subsequent infusion titration per Table 2
Repeat blood glucose in
30 minutes
Step 2. Subsequent Insulin Infusion Dosing:
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When blood glucose less than or equal to 250 mg/dL, contact MD/NP/PA for order to change of insulin
infusion rate to 0.05 units/kg/ hour OR continue current rate- if already equal to or less than 0.05
units/kg/hour
Contact MD/NP/PA for an order for dextrose containing IV fluids: Usual rate is 100-200 ml/hr
Titrate Insulin infusion using Table 2 below. Continue to round dose to the nearest 0.5 units/hour
TARGET GOAL: Keep Blood Glucose between 150 - 200 mg/dL until corrected anion gap is less than 14 for
two consecutive measurements
Notify MD/NP/PA if two consecutive rate increases are required
Table 2 – Subsequent Insulin Infusion (ON D5 CONTAINING FLUID)
Blood Glucose
greater than 250 mg/dL
201-250 mg/dL
150-200 mg/dL
80-149 mg/dL
less than or equal to 80 mg/dL
Insulin Infusion
Increase rate 50% (current rate x 1.5)
Increase rate 25% (current rate X 1.25)
Continue current rate
Decrease rate by 50% (current rate X 0.5)
 HOLD insulin infusion
 Notify MD/NP/PA
 Give 25ml D50 IVP
 Restart at 25% of previous rate (current rate X 0.25)
when Blood Glucose greater than 99 mg/dL
Adult Diabetic Ketoacidosis (DKA) Treatment Guideline
POC Glucose Monitoring
Repeat blood glucose in
1 hour
Repeat blood glucose in
30 minutes
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6. Transition from IV to Subcutaneous Insulin (SQ)
A. When to transition:

Three requirements should be met before you transition to SQ Insulin:
1. The anion gap has normalized in 2 consecutive blood samples (greater than 14 when corrected for
albumin).
2. The glucose values are within target of 150-200 mg/dL and insulin requirements are stable.
3. The patient is alert and able to tolerate clear liquids. Note full dietary intake is not required when
above requirements are met.
B. Dosage and Type of Insulin to administer:
 Definition: Total Daily Dose of Insulin (TDD) = estimated number of units of all types of insulin to be
given in 24 hours, e.g aspart (prandial and correction factor) plus glargine (Lantus)
1. Calculate the estimated Total Daily Dose (TDD)
A.
Patient receiving outpatient insulin therapy: Estimated TDD is equal to the sum of all insulin types
prescribed in outpatient insulin regimen.
B.
Patient NOT previously on insulin therapy: Estimated TDD is equal to 0.5 units/kg/day.
~OR~
2. Compare the estimated TDD to current intravenous insulin therapy:
(Current hourly insulin infusion rate x 24 hours = 24 hour IV insulin requirement)
A.
B.
If estimated TDD is less than current 24 hour intravenous insulin requirement then use the
average of the estimated TDD and 24 hour intravenous insulin requirement as the “Acute” TDD
to calculate subcutaneous regimen.
{(TDD + 24 hour intravenous insulin requirement) ÷ 2 = Average TDD}
If estimated TDD is greater than current 24 hour intravenous insulin requirement then use the
lesser TDD value to calculate subcutaneous regimen (consider a diabetes management consult).
3. Dosing and type of Insulin:
A.
B.
C.
Administer 50% of the TDD calculated from above as long acting Insulin, given once daily (basal,
insulin glargine) and administer 50% of the TDD calculated from above as rapid acting Insulin
(aspart), usually divided 3 times daily, administered with meals (prandial).
GIVE THE LONG ACTING SUBCUTANEOUS INSULIN (INSULIN GLARGINE) 2 HOURS
PRIOR TO DISCONTINUING IV INSULIN INFUSION.
Order Correction factor subcutaneous insulin, blood glucose monitoring and hypoglycemia
protocol.
4. Important Caveats:
 The instructions given above are based on consensus recommendations considering general
populations of patients
 Individual inpatient requirements for insulin may vary significantly:
o For patients taking insulin at home, the adequacy of glucose control at baseline will have an
impact on transition efficacy.
o In all patients with DKA or HHS, any unresolved precipitant may result in an
underestimation of the total insulin requirement (this would be reflected in the amount of
insulin required in the prior 1-2 hours vs. the estimated value based on weight).
 In all patients with resolving DKA or HHS, glucose and metabolic panels should be carefully
monitored to determine the optimal insulin regimen needed to obtain adequate glucose control
 The Diabetes Management Service, available through consult pager, can address questions regarding
insulin transition dosing or any other on-going diabetes management issues.
Adult Diabetic Ketoacidosis (DKA) Treatment Guideline
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