Mild DKA

Many studies have DKA resolving in under 16 hours with SQ insulin alone

Inclusion Criteria

  • Non-compliance with insulin
  • No other identifiable cause for DKA
  • All orders and protocol assumes previous treatment in the ED setting
  • ED work up must include VBG, CMP and evaluation for other causes of DKA
  • Mild-Moderate DKA as defined by
    • pH 7.15-7.3 (this is the ideal range)
    • HCO3 10-15 mmol/L
    • Serum or Urine ketones present
    • Anion Gap >10
  • if patient does not meet DKA criteria, please consider use of Hyperglycemia pathway

Exclusion Criteria

  • Persistently abnormal vital signs after 2L NS (SBP<100, HR >130, RR>24; MAP<60)
  • Severe DKA
    • pH < 7.0 (pH values between 7.0 and 7.14 should be clinically evaluated prior to acceptance)
    • Anion Gap >17
    • HCO3 < 10
  • Mental status changes
  • New onset DM
  • Acute co-morbidity / precipitant (infection, MI, surgery, trauma)
  • Hemodialysis patients
  • No direct admits to the unit. Definition of DKA must occur prior to placement in observation status.

Potential Interventions

During DKA:
  • Hydration at 250cc/hr with NS or ½ NS
  • Electrolyte replacement protocols of magnesium and potassium
  • Novalog - 0.2 u/kg Q2hour
  • Q 2hr – BS
  • BMP and Beta Hydroyxybutyrate on unit admission
  • Q 4 hour BMP, beta hydroxybutyrate and VBG.
  • Flow chart used
When Blood Sugar is under 250 (but still in DKA)
  • Fluids changed to D5 1/2NS at 125-250ml/hr
  • Insulin at Novalog to 0.1 u/kg Q2hour
  • D/C NPO status
At resolution of DKA
  • Criteria: BS <250; pH >7.3; Anion gap normal (<14); Bicarbonate normal (>18)
  • D/C IVF if
    • tolerating PO Diet
    • Patient received home long-acting insulin
  • Transition to subQ home dosing of insulin
    • 0.1u/kg novolog + patient’s home long acting insulin
    • If patient has not eaten yet, should be given food
    • If possible, dose home insulin and bolus before the next meal.
  • Decrease BS checks to QAC and HS

Discharge Criteria


  • Resolution of DKA for at least 4 hours
    • BS <250; pH >7.3; Anion gap normal (<14); Bicarbonate normal (>18)
  • Normal mentation
  • Normal vital signs
  • No acute co-morbid condition
  • Follow-up within 1-2 weeks


  • Failure to correct within 20 hours
  • Unable to tolerate PO
  • Worsening clinical picture or AG in observation unit.
  • Acute comorbid / precipitating condition identified
  • Significantly abnormal vital signs


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