Diabetic KetoacidosisICU / resuscitation

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Stopped insulin; hyperglycemia, anion-gap acidosis, ketones, Kussmaul

ABCDE

A-B secure; large-bore IV, NS bolus if shocked; check K⁺ before insulin; monitor + catheter; treat precipitant.

Diagnosis (2024 Int'l Consensus)

  • Glucose ≥200 mg/dL (or known diabetes regardless of glucose) + β-hydroxybutyrate (BOHB) ≥3.0 mmol/L — venous/capillary BOHB preferred over urine ketones — + pH <7.30 and/or HCO₃ <18; anion gap only supportive if ketones unavailable; severe = BOHB >6.0 mmol/L
Calculators:
  1. FIRST: Normal saline bolus (fluids) — pH/bicarbonate matter more than glucose
  2. Check K⁺ BEFORE insulin: K <3.3 → replace K first & hold insulin; 3.3–5.2 → add K to fluids; >5.2 → monitor
  3. Start: IV regular insulin continuous drip 0.1 U/kg/h (effect within 30 min; if none → re-bolus NS + insulin)
  4. When glucose <250 mg/dL → add dextrose and reduce infusion to 0.05 U/kg/h; continue until resolution = glucose <200 mg/dL AND venous pH >7.3 AND/OR bicarb ≥18 AND BOHB <0.6 mmol/L — anion gap is no longer a resolution criterion
  5. Bicarbonate: NOT recommended in DKA at any pH (no benefit on resolution, LOS, or outcomes; worsens hypokalemia — 2024 Int'l Consensus, ADA 2026)
Decision tree
K⁺ before insulin?
K⁺ <3.3
Hold insulin; replace K⁺ first
K⁺ 3.3–5.2
Add K⁺ to fluids; start insulin
K⁺ >5.2
Start insulin; monitor, replace K⁺ when it falls

Order set

  • VBG/ABG
  • Glucose, serum/POC β-hydroxybutyrate (BOHB — not urine ketones)
  • U&E (K⁺!), Mg, PO₄
  • Fluids (NS)
  • Insulin infusion
  • Septic screen, ECG

Monitor

  • 0 minFluids, VBG, K⁺, glucose, BOHB; start insulin drip
  • 1 hGlucose + K⁺ (expect glucose ↓ ~50–75/h)
  • 2 hVBG/HCO₃, BOHB, K⁺
  • 4 hElectrolytes; add dextrose when glucose <250
  • 6 hBOHB, K⁺, fluid balance
  • ResolutionBOHB <0.6 + pH >7.3 / HCO₃ ≥18 + glucose <200 → give basal SC insulin 1–2 h (2–4 h per ADA 2026) before stopping infusion

Escalate / ICU

  • pH <7.0 or HCO₃ <5
  • GCS drop / cerebral-edema signs
  • Refractory hypotension; K⁺ <3.3 or >6
  • Needs hourly insulin titration → HDU/ICU

Criteria

AdmitAll DKA
ICUpH <7.0, ↓GCS, K⁺ <3.3, shock, or need hourly titration
Intubate↓GCS with airway risk
DischargeResolution met (BOHB <0.6, pH >7.3/HCO₃ ≥18, glucose <200), eating, on SC insulin ≥24 h

Never

  • Stop IV insulin without overlapping basal SC insulin (1–2 h) → acidosis re-opens
  • Give bicarbonate in DKA at any pH (2024 consensus)
  • Reduce insulin infusion below 1 U/h before acidosis resolves
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
  • pH <7.0
  • GCS drop
  • K⁺ <3.3 or >6
  • Euglycemic DKA (SGLT2i, pregnancy, starvation): treat with insulin + dextrose-containing fluids; hold SGLT2i
Differentials
  • HHS (mixed DKA/HHS if BOHB ≥3 + glucose ≥600 + hyperosmolar)
  • Alcoholic/starvation ketosis
  • Lactic acidosis
Common mistakes
  • Insulin before checking K⁺
  • Stopping insulin before resolution/basal SC overlap
  • Bicarbonate routinely
Disposition & follow-up

HDU/ICU if severe; transition to SC insulin when resolved.

Discharge package
MedicationsResume/adjust insulin; sick-day rules
Follow-upDiabetes team review
LifestyleNever omit insulin; ketone monitoring when unwell
Warning symptomsVomiting, high glucose/ketones, drowsiness
💊 Treatment detail — doses & preparation
0.9% Sodium chloridecrystalloid
DoseBolus 500 mL over 15–30 min, reassess; maintenance 1–1.5 mL/kg/h
Preparation500/1000 mL bags; add KCl only after urine output confirmed
MonitorHyperchloraemic acidosis with large volumes — prefer balanced (LR) for resuscitation
Insulin regular IV (Actrapid)DKA infusion
Dose0.1 U/kg/h IV (0.05 if mild); never <1 U/h until acidosis resolves; add early basal insulin 0.15–0.3 U/kg alongside infusion; when glucose <250 mg/dL → add dextrose & reduce to 0.05 U/kg/h; stop only at resolution (BOHB <0.6 + pH >7.3/HCO₃ ≥18 + glucose <200) after basal SC overlap 1–2 h (2–4 h per ADA 2026). Mild uncomplicated DKA: SC rapid-acting insulin q1–2h is an alternative (non-ICU)
Preparation50 units in 50 mL NS (1 U/mL) via syringe pump; prime line (insulin binds plastic)
MonitorGlucose hourly, K⁺ q2–4 h — shift drops K⁺; never stop before ketones cleared
Potassium chlorideelectrolyte
DosePO 40–100 mmol/day divided. IV: 10 mmol/h peripheral, 20 mmol/h central with cardiac monitor
PreparationIV: NEVER undiluted push — 10 mmol in 100 mL or 40 mmol/L bag via pump
MonitorK⁺ q4–6 h during replacement, ECG, urine output >0.5 mL/kg/h
Dextrose 10% infusionhypoglycaemia/ALF
Dose100–200 mL/h of 10% titrated to glucose 5–8 mmol/L
Preparation500 mL/1 L bags; give with thiamine in at-risk patients
MonitorCapillary glucose q1–2 h in liver failure
📖 2024 Int'l DKA Consensus (Umpierrez) + ADA SoC 2026 §16Reviewed July 2026

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