Diabetic Ketoacidosis (DKA) — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] DKA diagnosis
   Does it meet the DKA triad? (1) Hyperglycemia (glucose >11.1 mmol/L; SGLT2i use / pregnancy can give euglycemic DKA) 2) Ketosis (β-hydroxybutyrate ≥3.0 mmol/L or marked ketonuria) 3) Metabolic acidosis (pH <7.3 and/or HCO3 <18 mmol/L). Anion gap is not a primary diagnostic criterion; use it when ketones are unavailable.)
   • Meets it (hyperglycemia + ketosis + acidosis) → Severity grading (2024 ADA)
   • Does not meet it → Not DKA
2. [End] Not DKA
   Does not meet DKA criteria. Evaluate other causes: hyperosmolar hyperglycemic state (HHS — higher glucose, mild ketosis, hyperosmolarity), lactic acidosis, starvation ketosis, other metabolic acidoses; treat the cause.
3. [Decision] Severity grading (2024 ADA)
   How severe? (Mild pH >7.25, HCO3 ≥15, alert; moderate pH 7.0–7.25, HCO3 10–<15; severe pH <7.0, HCO3 <10, β-hydroxybutyrate >6, stupor/coma. Grade determines level of monitoring; the management principles are the same.)
   • Mild–moderate (pH ≥7.0, alert/drowsy) → Standard DKA management
   • Severe (pH <7.0 / coma / critically ill) → Severe DKA → ICU
4. [End] Standard DKA management
   1) Fluids: 0.9% sodium chloride to restore volume and correct dehydration; adjust subsequent fluids by hemodynamics and corrected sodium. 2) Potassium (check before insulin): K <3.5 → give potassium 10 mmol/h first and hold insulin until K >3.5; K 3.5–5.0 → add potassium to maintain 4–5; K >5.0 → hold and monitor. 3) Insulin: regular insulin 0.1 U/kg/h continuous IV (fixed weight-based dose); when glucose falls to ~11–14 mmol/L add 5–10% dextrose and continue insulin to clear ketones. 4) Monitor: glucose 1–2 h, electrolytes/venous gas/β-hydroxybutyrate q4h; continue long-acting basal insulin. 5) Find the trigger (infection, missed therapy, new diabetes, SGLT2i, MI, etc.). Resolution = ketones <0.6 and (pH ≥7.3 or HCO3 ≥18) and glucose <11; transition to subcutaneous insulin (overlap 1–2 h). Bicarbonate only if pH <7.0; phosphate only if <1.0 with muscle weakness or cardiorespiratory involvement.
5. [End] Severe DKA → ICU
   Close monitoring in ICU/high-dependency (ECG, neuro, fluid balance). Management principles are the same as standard DKA (fluids → potassium-then-insulin 0.1 U/kg/h → monitor → find the trigger); bicarbonate may be considered if pH <7.0 (limited evidence). Watch for cerebral edema (especially children/young adults), hypokalemia, hypoglycemia and concurrent critical illness.

Source guidelines & references

• ADA/EASD 2024 consensus report on hyperglycemic crises in adults. Diabetes Care 2024;47(8):1257 · source ↗

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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