Appendix
Endocrinology / Critical Care

Diabetic Ketoacidosis (Adult)

Hyperglycemia, ketosis and anion-gap metabolic acidosis from insulin deficiency.

E10.10
E11.10
Reviewed 2026-07-18
  • pH < 7.0, HCO3 < 10, GCS < 12, K+ < 3.5 or > 6.0 → HDU/ICU
  • Do NOT start insulin if K+ < 3.3 mmol/L — replace potassium first
    GRADE 1B
  • Large-bore IV access; 0.9% NaCl 1 L over first hour
  • Glucose > 250 mg/dL (or known DM), pH < 7.3, HCO3 < 18, ketones ≥ 3 mmol/L
  • VBG, BMP, anion gap, serum β-hydroxybutyrate, osmolality
  • Search for precipitant: infection screen, ECG/troponin, lipase, pregnancy test
ADA DKA severity
Mild pH 7.25–7.30 · Moderate 7.00–7.24 · Severe < 7.00
  • Fluids → potassium → fixed-rate IV insulin, in that order
    GRADE 1B
  • Add dextrose 10% when glucose < 250 mg/dL; continue insulin until ketones clear
Regular insulin
IV infusion
Adult
0.1 U/kg/h fixed rate
Renal
Consider 0.05 U/kg/h in ESRD
Titration
Target ketone fall ≥ 0.5 mmol/L/h
Duration
Until resolution
0.1/kg
Potassium chloride
IV
Adult
20–30 mEq per L fluid if K+ 3.3–5.3
Renal
Reduce/withhold if oliguric
Duration
Per labs q2h
  • Mild uncomplicated DKA: SC rapid-acting insulin protocols acceptable
    GRADE 2B
  • Euglycemic DKA (SGLT2i): dextrose from start with insulin
  • Pregnancy: lower threshold, fetal monitoring, aggressive correction
  • Bicarbonate only if pH < 6.9
  • Glucose hourly, ketones/VBG/K+ q2h
  • Watch for hypokalemia, hypoglycemia, cerebral edema (young), fluid overload
  • Resolution: pH > 7.3, HCO3 ≥ 18, ketones < 0.6; overlap SC basal insulin 1–2 h before stopping IV
  • Diabetes education and endocrine follow-up before discharge
  • guideline
    Hyperglycemic Crises in Adults with Diabetes — Consensus Report — ADA/EASD/JBDS, 2024
  • guideline
    JBDS Management of DKA in Adults — JBDS-IP, 2023
  • review
    Diabetic Ketoacidosis — StatPearls, 2025

Decision support only. Verify against local protocols and current labeling.