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DKA diabetic ketoacidosis protocol diagnosis management treatment

Harrison's Principles of Internal Medicine, Twenty First Edition

Page 11347

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DKA diabetic ketoacidosis management protocol flowchart

Harrison's Principles of Internal Medicine, Twenty First Edition

Harrison's Principles of Internal Medicine, Twenty First Edition

Page 11343

GradeResponse
GradeResponse
Assuming you mean DKA protocol (diabetic ketoacidosis), here is a concise adult ER/ICU protocol.

1) Confirm DKA

Diagnosis is typically:
  • Glucose >250 mg/dL (can be lower in euglycemic DKA)
  • Metabolic acidosis: pH <7.30 and/or HCO3 ≤18 mEq/L
  • Ketosis: elevated serum beta-hydroxybutyrate or urine ketones
  • Usually elevated anion gap
Harrison’s lists representative DKA labs including glucose 250 to 600 mg/dL and typical electrolyte patterns (Harrison’s, p. 11343).

2) Immediate first hour

  1. ABCs, monitor, IV access, cardiac monitor
  2. Labs: BMP, venous/arterial blood gas, ketones, CBC, osmolality, Mg, phosphate, ECG, infection workup if indicated
  3. Start fluids:
    • 0.9% saline 15 to 20 mL/kg in first hour (about 1 to 1.5 L in most adults)

3) Potassium-guided insulin start

  • K <3.3 mEq/L: hold insulin, give K first (usually 20 to 30 mEq/h) until >3.3
  • K 3.3 to 5.2: start insulin + add K to IV fluids (20 to 30 mEq per liter)
  • K >5.2: start insulin, no K initially, recheck frequently

4) Insulin therapy

  • Regular insulin IV:
    • 0.1 U/kg bolus then 0.1 U/kg/h, or
    • 0.14 U/kg/h without bolus
  • Goal glucose drop: about 50 to 75 mg/dL per hour

5) Ongoing fluids and dextrose transition

  • After first hour, choose fluid by corrected sodium:
    • low Na: continue 0.9% saline
    • normal/high Na: 0.45% saline
  • When glucose reaches ~200 mg/dL (DKA), add D5-containing fluid and reduce insulin rate (often 0.02 to 0.05 U/kg/h) to continue clearing ketones and closing anion gap.

6) Bicarbonate and phosphate

  • Bicarbonate: generally avoid unless severe acidemia (commonly pH <6.9)
  • Phosphate: not routine; replace if severe hypophosphatemia, cardiac dysfunction, respiratory weakness, or other specific indications

7) Monitoring

  • Hourly bedside glucose
  • Electrolytes, anion gap, bicarbonate, creatinine every 2 to 4 hours
  • Strict input/output, mental status, vitals
  • Search and treat precipitating cause (infection, missed insulin, MI, stroke, pancreatitis, drugs). Harrison’s emphasizes identifying and treating triggers and close reassessment (p. 11347).

8) Resolution criteria (typical)

DKA resolved when:
  • glucose <200 mg/dL and
  • two of:
    • bicarbonate ≥15 mEq/L
    • pH >7.30
    • anion gap normalized

9) Transition IV to subcutaneous insulin

  • Give long-acting basal insulin
  • Overlap IV insulin for 1 to 2 hours after first SC dose to prevent rebound ketosis
  • Ensure patient can eat and cause is addressed

Useful reference image

DKA lab profile table
If you want, I can give this as a one-page bedside order set (fluids, insulin, potassium, and lab timing) for quick use in adults, or a pediatric-specific protocol (which differs).
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