Diabetic KetoacidosisICU / resuscitation

Type 1 diabetes, stopped insulin 2 days ago; vomiting, abdominal pain, Kussmaul breathing; glucose 420 mg/dL, pH 7.12, HCO₃ 9, BOHB 5.8 mmol/L

• pH <7.0 or HCO₃ <5
• Falling GCS, headache, bradycardia (cerebral oedema)
• K⁺ <3.5 or >6
• Hypotension after 2 L
• Euglycaemic DKA (SGLT2 inhibitor, pregnancy)

• HHS / mixed DKA-HHS (glucose ≥600 + osmolality >300 + BOHB ≥3)
• Alcoholic or starvation ketoacidosis (glucose normal or low)
• Lactic acidosis, toxic alcohols, salicylate
• Surgical abdomen (pain from DKA settles as acidosis clears)

• Admit: All DKA
• ICU/HDU: pH <7.0, HCO₃ <5, BOHB >6, K⁺ <3.5, GCS <12, SBP <90, SpO₂ <92%, or anion gap >16 (JBDS severity markers)
• Intubate: Falling GCS with airway risk, exhaustion

• Glucose ≥200 mg/dL (or known diabetes regardless of glucose) + β-hydroxybutyrate (BOHB) ≥3.0 mmol/L — blood BOHB preferred over urine ketones — + pH <7.30 and/or HCO₃ <18 mmol/L; severe = pH <7.0 or HCO₃ <10 (BOHB >6 mmol/L is a JBDS severity marker)

• Start insulin without knowing the K⁺ — K⁺ <3.5 means hold insulin
• Stop IV insulin without an overlapping SC basal dose
• Give bicarbonate unless pH <7.0
• Stop insulin because the glucose is normal — add dextrose instead
• Judge resolution by urine ketones or glucose

• Insulin before the K⁺ is known
• Stopping the infusion without basal overlap
• Routine bicarbonate
• Chasing glucose instead of ketones
• Missing the precipitant

HDU/ICU with any JBDS severity marker; otherwise ward with hourly monitoring. Diabetes team review and sick-day education before discharge.