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Adult Diabetic Ketoacidosis (DKA) Management Algorithm

Adult Diabetic Ketoacidosis (DKA) Management Algorithm - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Diabetes and Endocrinology, Related

K+ <3.3 mEq/L K+ > 5.2 mEq/L
Establish adequate urine output of ≥50 ml/hr,
then replete, if necessary
Ensure adequate potassium level before
starting insulin therapy
Check blood gases, serum glucose, sodium, potassium, bicarb, chloride, anion gap, CBC with differential, SCr, beta-hydroxybutyrate, and a UA. Order a HbA1C, if not done in last 90 days. Start IV fluids: 1 L NS over 1 hour

For a patient in HHS, use an IV solution containing 5% dextrose when blood glucose declines to 300 mg/dL or lower.
Hourly glucose monitoring required every hour until glucose within target range of 110-150 mg/dL for 3 hours, then check every 2 hours. Resume hourly monitoring if
blood glucose deviates from the target range. Check electrolytes and phosphate level every 2 hours times two, then every 4 hours. Check a beta-hydroxybutyrate level
every 8 hours. Identify and treat the cause of the DKA precipitation.
Once the patient is able to eat and the DKA episode is resolved (as demonstrated by pH >7.3, bicarbonate >18 mmol/L, and blood glucose <200 mg/dL), transition the
patient to subcutaneous (SQ) insulin. Overlap the insulin drip with the SQ insulin by 2 or more hours. For an insulin-naïve patient, calculate the daily insulin dose
received via insulin infusion in the last 24 hours, decrease by 20%, and split the remainder up as ½ basal insulin and ½ mealtime insulin (mealtime dose to be divided
between all meals). References: Nyenwe EA, Kitabchi AE. Evidence-based management of hyperglycemic emergencies in diabetes mellitus. Diabetes Research and Clinical Practice.
2011;94:340-351. Association AD. Professional Practice Committee for the Standards of Medical Care in Diabetes-2017. Diabetes Care. Jan 2017;40 Suppl 1:S1-135.
K+ 3.3 to 5.2 mEq/L
Before starting insulin
therapy, give 10-20 mEq
K+ per hour in IV fluids
until K+ >3.3 mEq/L‡
Do not supplement K+
but check K+ level every
2 hours
Give 10-20 mEq/L of K+ in IV fluids to maintain
K+ level between 4 and 5 mEq/L‡
Use an IV solution containing 5%
dextrose when blood glucose declines
to 200 mg/dL† or lower
Give 0.9% NaCl
at rate of 1 L/hr Hemodynamic monitoring/pressors
Evaluate hydration status
Cardiogenic shock
Use Standard Dose Insulin Infusion –
Adult – Practice Protocol
IV Fluids
Evaluate corrected serum Na+ concentration
Na+corrected = Na+ measured + [(glucose-100)/100]*1.6
Normal or high
serum Na+
Low serum
0.45% NaCl at rate
of 250-500 mL/hr
0.9% NaCl at rate
of 250-500 mL/hr
‡ K+ Infusion rates ≥20 mEq/hr require a cardiac monitor.
Maximum recommended rate for peripheral K+ administration is
no greater than 10 mEq/hr. Sliding Scale potassium only allowed
on B4/3, B4/5, B6N3, B6S3, D4/5, D6/5 IMC, F4/5, F4M5, F8/4
UWHC DKA Management Algorithm (Adult Patients)
Last updated: 2/23/2017 | Last Reviewed 3/23/2017 Questions? Contact Inpatient Diabetes Quality Committee Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org