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Figure 1: Recommended Management of DKA from the Canadian Diabetes Association Management of DKA
Key Management Points:
Key Management Points:
Insulin is administered to close the anion gap
Fluid is used to:
Correct the volume deficit
Resolve hyperglycemia
Patients tend to be intravascularly hyperkalemic (shift from metabolic acidosis) at presentation but whole body deplete of potassium (due to urinary losses). Do not be surprised if potassium drops rapidly after administration - remember that insulin shifts potassium intracellularly
Maintain NPO while patient is actively being treated for DKA
Assess for precipitating factors
Other Resources:
Other Resources:
CMAJ: Diagnosis and Treament of DKA/HHS
Canadian Diabetes Association: Hyperglycemic Emergencies in Adults
The Intern at Work DKA Management
Frequently Asked Questions
Frequently Asked Questions
When to call ICU/CCRT?
When to call ICU/CCRT?
Severe DKA
pH < 7.1
Altered LOC
Hypotension not responding to fluids
Poor venous access requiring central line
What if the glucose is falling but the Anion Gap isn't closing?
What if the glucose is falling but the Anion Gap isn't closing?
In this scenario, add glucose to the fluid and increase your insulin drip (ie. use of D5W, D10W, 2/3+1/3 etc.)
Remember that the ANION GAP responds to INSULIN, and the HYPERGLYCEMIA responds to FLUID administration
What is the evidence for sodium bicarbonate administration?
What is the evidence for sodium bicarbonate administration?
In general, the evidence for bicarbonate administration is weak. Some individuals may choose to use bicarbonate infusion (3 amps Bicarb in 850 mL D5W) as a crystalloid for individuals with a pH < 7.0. However, in general, acidosis will be treated by insulin administration which treats the ketoacidosis.
When should I transition the patient to subcutaneous insulin?
When should I transition the patient to subcutaneous insulin?
Most transitions for the patient should occur in the morning after the patient has eaten breakfast.
Patients are ready to be transitioned when they are:
AG closes
BG < 15mM
Insulin requirements are 0.5-1 unit per hour or requiring near baseline insulin requirements
Patient is hungry and tolerating PO intake
Patient can be closely monitored during the transition
Overlap IV insulin with subcutaneous long-acting basal insulin for 2-4 hours before stopping your insulin infusion altogether
Last updated: October 2021
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