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Diabetic Ketoacidosis (DKA)

Also known as: DKA · diabetic coma · ketoacidosis

An acute hyperglycaemic emergency of insulin deficiency — hyperglycaemia, ketosis and metabolic acidosis. Fluids, fixed-rate insulin and potassium are the pillars of treatment.

Source · Reviewed 2026-08-15 · v1.0— AI-assisted draft — verify against the cited guideline before clinical use.

⚕️ Education only — not medical advice. Verify against the latest official guideline and your local protocol; confirm every drug dose against the cited source before clinical use.

Who gets it

People with type 1 diabetes (may be the first presentation); also type 2 under stress. Precipitants: infection, missed insulin, new diagnosis, MI, and some drugs.

Red flags — escalate / refer

Drowsiness/coma, Kussmaul breathing, severe dehydration or shock → high-dependency care.
Potassium derangement, very low pH, or a serious precipitant (sepsis, MI) → escalate.
Children are at particular risk of cerebral oedema — avoid over-rapid fluids.

Work-up / diagnosis

1Confirm the triad: hyperglycaemia (glucose usually >250 mg/dL; can be lower in euglycaemic DKA), ketonaemia/ketonuria, and metabolic acidosis (pH <7.3 or HCO₃ <15).
2Send glucose, blood ketones, venous/arterial gas, and electrolytes — watch potassium closely.
3Actively look for the precipitant (infection, missed insulin, MI).

Management — overview

Fluids FIRST: IV 0.9% sodium chloride to restore circulating volume (individualise the rate); this alone lowers glucose.
Start a fixed-rate IV insulin infusion; continue any long-acting (basal) insulin the patient normally takes.
Replace potassium: add KCl to fluids once K⁺ is below the upper-normal range with urine output; HOLD insulin if K⁺ <3.3 mmol/L until replaced.
Add glucose-containing fluid once blood glucose falls (so insulin can keep clearing ketones).
Monitor hourly glucose/ketones/potassium, treat the precipitant, and switch to subcutaneous insulin (overlapping the infusion) once ketoacidosis resolves.

Step-by-step protocolpathway

1Recognise & resuscitate (hour 0): assess A–B–C and conscious level, secure large-bore IV access, and send glucose, blood/urine ketones, venous gas and U&E (watch potassium) — plus a precipitant screen (FBC, cultures, ECG, CXR as indicated).
2Fluids FIRST: start IV 0.9% sodium chloride to restore circulating volume, individualising the rate for age and cardiac/renal status (cautious in the young, elderly and frail) — fluid alone lowers glucose.
3Insulin: begin a FIXED-RATE IV insulin infusion (about 0.1 unit/kg/hour) and CONTINUE the patient’s usual long-acting (basal) insulin; do not give an insulin bolus in children.
4Potassium: once K⁺ is below the upper-normal limit and urine is flowing, add potassium to the fluids to keep K⁺ ~4–5 mmol/L — and HOLD insulin if K⁺ is <3.3 mmol/L until it is replaced.
5Monitor hourly: capillary glucose and ketones every hour, with venous gas/bicarbonate and U&E at set intervals; track fluid balance and urine output.
6Add glucose when the glucose falls (about <14 mmol/L / 250 mg/dL): run a glucose-containing infusion alongside the saline so insulin can keep clearing ketones without causing hypoglycaemia.
7Aim for resolution — ketones <0.6 mmol/L (or venous pH >7.3 and bicarbonate >18 mmol/L) with the patient eating and drinking; avoid routine bicarbonate.

8Convert to subcutaneous insulin only after ketoacidosis has resolved: give the SC dose and OVERLAP it with the infusion (about 30–60 minutes) before stopping the drip, and involve the diabetes team.
9Throughout: treat the precipitant and ESCALATE to senior/critical care for reduced consciousness, a pH that is not improving, potassium derangement, pregnancy or any red flag — in children, use cautious fluids and watch closely for cerebral oedema.

An educational pathway — NOT a hospital order set. Always follow your unit’s approved DKA protocol and senior guidance; confirm all rates and thresholds locally.

ICMRStandard Treatment Workflows (STWs), India — Dept. of Health Research & ICMR (2022+) ↗

In-depthFull dosing & advanced protocol

Drug dosing

IV 0.9% sodium chloride

Volume restoration (first-line)

Adult dose: Rapid initial replacement then maintenance per protocol; adjust for cardiac/renal/elderly
Route: Intravenous

ICMRStandard Treatment Workflows (STWs), India — Dept. of Health Research & ICMR (2022+) ↗

Fixed-rate IV insulin infusion (soluble/regular)

Clear ketones & correct hyperglycaemia

Adult dose: 0.1 unit/kg/hour IV; titrate to a steady fall in ketones/glucose
Route: Intravenous infusion

Caution: Continue basal insulin; do not stop the infusion until ketoacidosis has cleared.

ICMRStandard Treatment Workflows (STWs), India — Dept. of Health Research & ICMR (2022+) ↗

Potassium chloride

Prevent/treat hypokalaemia

Adult dose: Add to fluids to keep K⁺ ~4–5 mmol/L; hold insulin if K⁺ <3.3
Route: Intravenous

Caution: Requires urine output and monitoring; avoid routine bicarbonate.

ICMRStandard Treatment Workflows (STWs), India — Dept. of Health Research & ICMR (2022+) ↗

Pitfalls & special situations

Euglycaemic DKA (notably with SGLT2 inhibitors): ketoacidosis with only modestly raised glucose — don’t be reassured by the glucose.
Paediatric DKA: cautious fluids and close neuro-observation for cerebral oedema.
Distinguish from hyperosmolar hyperglycaemic state (HHS): higher glucose, minimal ketones/acidosis, marked dehydration.

ICMRStandard Treatment Workflows (STWs), India — Dept. of Health Research & ICMR (2022+) ↗

References

Guidelines change. If something here is out of date, tell us — we keep these current.

🚩 Report outdated / suggest update

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Diabetic Ketoacidosis (DKA)

Also known as: DKA · diabetic coma · ketoacidosis

An acute hyperglycaemic emergency of insulin deficiency — hyperglycaemia, ketosis and metabolic acidosis. Fluids, fixed-rate insulin and potassium are the pillars of treatment.

Source · Reviewed 2026-08-15 · v1.0— AI-assisted draft — verify against the cited guideline before clinical use.

Work-up / diagnosis

1Confirm the triad: hyperglycaemia (glucose usually >250 mg/dL; can be lower in euglycaemic DKA), ketonaemia/ketonuria, and metabolic acidosis (pH <7.3 or HCO₃ <15).

2Send glucose, blood ketones, venous/arterial gas, and electrolytes — watch potassium closely.

3Actively look for the precipitant (infection, missed insulin, MI).

Management — overview

Fluids FIRST: IV 0.9% sodium chloride to restore circulating volume (individualise the rate); this alone lowers glucose.

Start a fixed-rate IV insulin infusion; continue any long-acting (basal) insulin the patient normally takes.

Replace potassium: add KCl to fluids once K⁺ is below the upper-normal range with urine output; HOLD insulin if K⁺ <3.3 mmol/L until replaced.

Add glucose-containing fluid once blood glucose falls (so insulin can keep clearing ketones).

Monitor hourly glucose/ketones/potassium, treat the precipitant, and switch to subcutaneous insulin (overlapping the infusion) once ketoacidosis resolves.

Step-by-step protocolpathway

1Recognise & resuscitate (hour 0): assess A–B–C and conscious level, secure large-bore IV access, and send glucose, blood/urine ketones, venous gas and U&E (watch potassium) — plus a precipitant screen (FBC, cultures, ECG, CXR as indicated).

2Fluids FIRST: start IV 0.9% sodium chloride to restore circulating volume, individualising the rate for age and cardiac/renal status (cautious in the young, elderly and frail) — fluid alone lowers glucose.

3Insulin: begin a FIXED-RATE IV insulin infusion (about 0.1 unit/kg/hour) and CONTINUE the patient’s usual long-acting (basal) insulin; do not give an insulin bolus in children.

4Potassium: once K⁺ is below the upper-normal limit and urine is flowing, add potassium to the fluids to keep K⁺ ~4–5 mmol/L — and HOLD insulin if K⁺ is <3.3 mmol/L until it is replaced.

5Monitor hourly: capillary glucose and ketones every hour, with venous gas/bicarbonate and U&E at set intervals; track fluid balance and urine output.

6Add glucose when the glucose falls (about <14 mmol/L / 250 mg/dL): run a glucose-containing infusion alongside the saline so insulin can keep clearing ketones without causing hypoglycaemia.

7Aim for resolution — ketones <0.6 mmol/L (or venous pH >7.3 and bicarbonate >18 mmol/L) with the patient eating and drinking; avoid routine bicarbonate.

8Convert to subcutaneous insulin only after ketoacidosis has resolved: give the SC dose and OVERLAP it with the infusion (about 30–60 minutes) before stopping the drip, and involve the diabetes team.
9Throughout: treat the precipitant and ESCALATE to senior/critical care for reduced consciousness, a pH that is not improving, potassium derangement, pregnancy or any red flag — in children, use cautious fluids and watch closely for cerebral oedema.

An educational pathway — NOT a hospital order set. Always follow your unit’s approved DKA protocol and senior guidance; confirm all rates and thresholds locally.

Drug dosing

IV 0.9% sodium chloride

Volume restoration (first-line)

Adult dose: Rapid initial replacement then maintenance per protocol; adjust for cardiac/renal/elderly
Route: Intravenous

ICMRStandard Treatment Workflows (STWs), India — Dept. of Health Research & ICMR (2022+) ↗

Fixed-rate IV insulin infusion (soluble/regular)

Clear ketones & correct hyperglycaemia

Adult dose: 0.1 unit/kg/hour IV; titrate to a steady fall in ketones/glucose
Route: Intravenous infusion

Caution: Continue basal insulin; do not stop the infusion until ketoacidosis has cleared.

ICMRStandard Treatment Workflows (STWs), India — Dept. of Health Research & ICMR (2022+) ↗

Potassium chloride

Prevent/treat hypokalaemia

Adult dose: Add to fluids to keep K⁺ ~4–5 mmol/L; hold insulin if K⁺ <3.3
Route: Intravenous

Caution: Requires urine output and monitoring; avoid routine bicarbonate.

ICMRStandard Treatment Workflows (STWs), India — Dept. of Health Research & ICMR (2022+) ↗

Pitfalls & special situations

Euglycaemic DKA (notably with SGLT2 inhibitors): ketoacidosis with only modestly raised glucose — don’t be reassured by the glucose.

Paediatric DKA: cautious fluids and close neuro-observation for cerebral oedema.

Distinguish from hyperosmolar hyperglycaemic state (HHS): higher glucose, minimal ketones/acidosis, marked dehydration.

👤 Who gets it

🚩 Red flags — escalate / refer

🔎 Work-up / diagnosis

🧭 Management — overview

🧾 Step-by-step protocolpathway

💊 Drug dosing

IV 0.9% sodium chloride

Fixed-rate IV insulin infusion (soluble/regular)

Potassium chloride

📈 Pitfalls & special situations

📚 References

More protocols

👤 Who gets it

🚩 Red flags — escalate / refer

🔎 Work-up / diagnosis

🧭 Management — overview

🧾 Step-by-step protocolpathway

💊 Drug dosing

IV 0.9% sodium chloride

Fixed-rate IV insulin infusion (soluble/regular)

Potassium chloride

📈 Pitfalls & special situations

📚 References

More protocols

Who gets it

Red flags — escalate / refer

Work-up / diagnosis

Management — overview

Step-by-step protocolpathway

Drug dosing

Pitfalls & special situations

References

Who gets it

Red flags — escalate / refer

Work-up / diagnosis

Management — overview

Step-by-step protocolpathway

Drug dosing

Pitfalls & special situations

References