Diabetic Ketoacidosis (DKA)

DKA is defined by the triad: glucose >11mmol/L (or known DM), ketonaemia ≥3mmol/L or urine ketones 2+, and acidosis (pH <7.3 or bicarbonate <15). Severity: moderate pH <7.2, severe pH <7.0. IV fluid resuscitation is the most important initial…

JBDS DKA Protocol

The pathway

1 · Confirm DKA

BM >11, ketones ≥3mmol/L (blood ketones preferred), pH <7.3 or bicarb <15. ECG for hyperkalaemia. Venous blood gas + U&E urgently.

2 · IV fluid resuscitation

0.9% NaCl 1L over 1 hour stat. Then 1L over 2h, 1L over 2h, 1L over 4h, 1L over 4h, 1L over 6h. Total ~6L over 24h. Reassess frequently.

3 · Fixed-rate insulin infusion (FRIII)

Start ONLY after fluid resuscitation has begun. 0.1 units/kg/hr of Actrapid (or soluble insulin) in 0.9% NaCl. Do NOT bolus insulin.

4 · Potassium replacement

K+ 3.5–5.5: add 40mmol KCl per litre fluid
K+ <3.5: stop insulin, give K+ replacement urgently
K+ >5.5: no K+ in fluids, check ECG

5 · Glucose management

When BM <14mmol/L: add 10% glucose 125ml/hr alongside FRIII. Do NOT stop insulin unless ketones <0.3 and pH >7.3 — insulin drives ketone clearance.

6 · Resolution criteria & switch to SC insulin

Ketones <0.3mmol/L AND pH >7.3 AND patient eating/drinking: Give SC insulin (usual regimen or new regimen if newly diagnosed)
FRIII can stop 30–60 min after first SC dose

Drugs

Drug	Dose	Route	Notes
0.9% NaCl	1L	IV	First bag over 1h. Adjust rate per protocol. ~6L over 24h total.
Actrapid (soluble insulin)	0.1 units/kg/hr	IV infusion	Fixed rate. Do NOT bolus. Do NOT start before IV fluids.
KCl 40mmol	40mmol per litre	IV (pre-mixed)	Add to bags if K+ 3.5–5.5. Check K+ 2-hourly.
10% Dextrose	125ml/hr	IV	Start when BM <14mmol/L. Run alongside FRIII.

When to escalate

pH <7.0 (severe DKA) — ITU referral,GCS <12 — airway risk, ITU,Oliguria / AKI despite fluids,K+ <3.0 — urgent replacement, consider stopping insulin,Not clearing ketones after 6h — check line, insulin, consider increasing FRIII

Reference: JBDS-IP DKA Management Guidelines 2023

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