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Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment

Authors: Irl B Hirsch, MD, Michael Emmett, MD
Section Editor: David M Nathan, MD
Deputy Editor: Jean E Mulder, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Sep 2020. | This topic last updated: Jul 27, 2020.

INTRODUCTION

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS, also known as hyperosmotic hyperglycemic nonketotic state
[HHNK]) are two of the most serious acute complications of diabetes. They are part of the spectrum of hyperglycemia, and each
represents an extreme in the spectrum.

The treatment of DKA and HHS in adults will be reviewed here. The epidemiology, pathogenesis, clinical features, evaluation, and
diagnosis of these disorders are discussed separately. DKA in children is also reviewed separately.

● (See "Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Epidemiology and pathogenesis".)
● (See "Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Clinical features, evaluation, and diagnosis".)
● (See "Diabetic ketoacidosis in children: Clinical features and diagnosis".)
● (See "Diabetic ketoacidosis in children: Treatment and complications".)

DEFINITIONS

DKA and HHS differ clinically according to the presence of ketoacidosis and, usually, the degree of hyperglycemia [1-3]. The definitions
proposed by the American Diabetes Association (ADA) for DKA and HHS are shown in the table ( table 1) [1].

● In DKA, metabolic acidosis is often the major finding, while the serum glucose concentration is generally below 800 mg/dL (44.4
mmol/L) and often in the 350 to 500 mg/dL (19.4 to 27.8 mmol/L) range [1-3]. However, serum glucose concentrations may exceed
900 mg/dL (50 mmol/L) in patients with DKA, most of whom are comatose [3,4], or may be normal or minimally elevated (<250
mg/dL [13.9 mmol/L]) in patients with euglycemic DKA (which occurs more often in patients with poor oral intake, those treated with
insulin prior to arrival in the emergency department, pregnant women, and those who use sodium-glucose co-transporter 2 [SGLT2]
inhibitors).

● In HHS, there is little or no ketoacid accumulation, the serum glucose concentration frequently exceeds 1000 mg/dL (56 mmol/L),
the plasma osmolality (Posm) may reach 380 mOsmol/kg, and neurologic abnormalities are frequently present (including coma in 25
to 50 percent of cases) [1,2,5,6].

The typical total body deficits of water and electrolytes in DKA and HHS are compared in the table ( table 2). (See "Diabetic ketoacidosis
and hyperosmolar hyperglycemic state in adults: Clinical features, evaluation, and diagnosis", section on 'Serum glucose' and "Diabetic
ketoacidosis and hyperosmolar hyperglycemic state in adults: Clinical features, evaluation, and diagnosis", section on 'Diagnostic
criteria'.)

TREATMENT

Overview and protocols — The treatment of DKA ( algorithm 1) and HHS ( algorithm 2) is similar, including correction of the fluid
and electrolyte abnormalities that are typically present (hyperosmolality, hypovolemia, metabolic acidosis [in DKA], and potassium
depletion) and the administration of insulin [1,7-9].

● Correction of fluid and electrolyte abnormalities – The first step in the treatment of DKA or HHS is infusion of isotonic saline to
expand extracellular volume and stabilize cardiovascular status ( table 3). This also increases insulin responsiveness by lowering
the plasma osmolality (Posm), reducing vasoconstriction and improving perfusion, and reducing stress hormone levels [10,11]. The
next step is correction of the potassium deficit (if present). The choice of fluid replacement should be influenced by the potassium
:
 deficit. The osmotic effect of potassium repletion must be considered since potassium is as osmotically active as sodium. (See 'Fluid
replacement' below and 'Potassium replacement' below.)

● Administration of insulin – Low-dose intravenous (IV) insulin should be administered to all patients with moderate to severe DKA
who have a serum potassium ≥3.3 mEq/L. If the serum potassium is less than 3.3 mEq/L, insulin therapy should be delayed until
potassium replacement has begun and the serum potassium concentration has increased. The delay is necessary because insulin
will worsen the hypokalemia by driving potassium into the cells, and this could trigger cardiac arrhythmias. IV regular insulin and
rapid-acting insulin analogs are equally effective in treating DKA. (See 'Insulin' below.)

Therapy requires frequent clinical and laboratory monitoring and the identification and treatment of any precipitating events, including
infection. Sodium-glucose co-transporter 2 (SGLT2) inhibitors, which can precipitate DKA, should be discontinued. (See 'Monitoring'
below and "Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Clinical features, evaluation, and diagnosis", section
on 'Precipitating factors'.)

Our approach outlined below is based upon clinical experience and is largely in agreement with the American Diabetes Association (ADA)
consensus algorithms for the treatment of DKA ( algorithm 1) and HHS ( algorithm 2) and the Joint British Diabetes Societies
guideline for the management of DKA [1,12,13].

Fluid replacement — In patients with DKA or HHS, we recommend IV electrolyte and fluid replacement to correct both hypovolemia and
hyperosmolality. Fluid repletion is usually initiated with isotonic saline (0.9 percent sodium chloride [NaCl]). Patients with euglycemic
DKA generally require both insulin and glucose to treat the ketoacidosis and prevent hypoglycemia, respectively, and in such patients,
dextrose is added to IV fluids at the initiation of therapy. For patients with a more classic presentation of hyperglycemic DKA, we add
dextrose to the saline solution when the serum glucose declines to 200 mg/dL (11.1 mmol/L) in DKA ( algorithm 1) or 250 to 300
mg/dL (13.9 to 16.7 mmol/L) in HHS ( algorithm 2).

The optimal rate of initial isotonic saline infusion is dependent upon the clinical state of the patient:

● In patients with hypovolemic shock, isotonic saline should be infused as quickly as possible. (See "Treatment of severe hypovolemia
or hypovolemic shock in adults".)

● In hypovolemic patients without shock (and without heart failure), isotonic saline is infused at a rate of 15 to 20 mL/kg lean body
weight per hour (approximately 1000 mL/hour in an average-sized person) for the first couple of hours, with a maximum of <50
mL/kg in the first four hours ( algorithm 1 and algorithm 2) [1].

● In euvolemic patients, isotonic saline is infused at a lower rate, guided by clinical assessment.

After the second or third hour, optimal fluid replacement depends upon the state of hydration, serum electrolyte levels, and the urine
output. The most appropriate IV fluid composition is determined by the sodium concentration "corrected" for the degree of
hyperglycemia. The "corrected" sodium concentration can be approximated by adding 2 mEq/L to the plasma sodium concentration for
each 100 mg/100 mL (5.5 mmol/L) increase above normal in glucose concentration (calculator 1).

If the "corrected" serum sodium concentration is [1]:

● Less than 135 mEq/L, isotonic saline should be continued at a rate of approximately 250 to 500 mL/hour

● Normal or elevated, the IV fluid is generally switched to one-half isotonic saline at a rate of 250 to 500 mL/hour in order to provide
electrolyte-free water

The timing of one-half isotonic saline therapy may also be influenced by potassium balance. Potassium repletion affects the saline
solution that is given since potassium is as osmotically active as sodium. Thus, concurrent potassium replacement may be another
indication for the use of one-half isotonic saline. (See 'Potassium replacement' below.)

Adequate rehydration with correction of the hyperosmolar state may enhance the response to low-dose insulin therapy [10,11].
Adequacy of fluid replacement is judged by frequent hemodynamic and laboratory monitoring (see 'Monitoring' below). In patients with
abnormal renal or cardiac function, more frequent monitoring must be performed to avoid iatrogenic fluid overload [8,9,11,14-17]. The
goal is to correct estimated deficits ( table 2) within the first 24 hours. However, osmolality should not be reduced too rapidly, because
this may generate cerebral edema. (See 'Cerebral edema' below and "Diabetic ketoacidosis in children: Treatment and complications",
section on 'Cerebral injury'.)

Potassium replacement — Potassium replacement is initiated immediately if the serum potassium is <5.3 mEq/L as long as there is
adequate urine output (approximately >50 mL/hour) ( algorithm 1). Almost all patients with DKA or HHS have a substantial potassium
:
deficit, usually due to urinary losses generated by the glucose osmotic diuresis and secondary hyperaldosteronism. Despite the total
body potassium deficit, the serum potassium concentration is usually normal or, in approximately one-third of cases, elevated at
presentation. This is largely due to insulin deficiency and hyperosmolality, each of which cause potassium movement out of the cells
[18].

● If the initial serum potassium is below 3.3 mEq/L, IV potassium chloride (KCl; 20 to 40 mEq/hour, which usually requires 20 to 40
mEq/L added to saline) should be given. The choice of replacement fluid (isotonic or one-half isotonic saline) depends upon the state
of hydration, corrected sodium concentration, dose of KCl, blood pressure, and a clinical assessment of overall volume status.
Patients with marked hypokalemia require aggressive potassium replacement (40 mEq/hour, with additional supplementation based
upon hourly serum potassium measurements) to raise the serum potassium concentration into the normal range of 4 to 5 mEq/L
[19-21].

● If the initial serum potassium is between 3.3 and 5.3 mEq/L, IV KCl (20 to 30 mEq) is added to each liter of IV replacement fluid and
continued until the serum potassium concentration has increased to the 4 to 5 mEq/L range.

● If the initial serum potassium concentration is greater than 5.3 mEq/L, then potassium replacement should be delayed until its
concentration has fallen below this level.

Potassium salts added to IV fluids have the same osmotic effect as sodium salts, and this should be considered when determining the
potential impact of IV fluid infusion on osmolality. As an example, 40 mEq of KCl added to 1 L of fluid generates 80 mOsmol/L of
electrolyte osmolality. The addition of 40 mEq of potassium to 1 L of one-half isotonic saline creates a solution with an osmolality of 234
mOsmol/L (77 mEq NaCl and 40 mEq KCl), which is osmotically equal to three-quarters isotonic saline. (The osmolality of isotonic saline is
308 mOsmol/L.) If 40 mEq of KCl is added to isotonic saline, the final osmolality will be approximately 388 mOsmol/L. However, KCl will
not have the same extracellular fluid (ECF) expansion effect as NaCl, because most of the potassium will shift into cells very rapidly. (See
"Maintenance and replacement fluid therapy in adults", section on 'Choice of replacement fluid'.)

The altered potassium distribution is rapidly reversed with the administration of insulin and can result in an often dramatic fall in the
serum potassium concentration, despite potassium replacement [19,20]. However, potassium replacement must be done cautiously if
renal function remains depressed and/or urine output does not increase to a level >50 mL/hour. Careful monitoring of the serum
potassium is essential for the management of both DKA and HHS. (See 'Monitoring' below and "Diabetic ketoacidosis and hyperosmolar
hyperglycemic state in adults: Epidemiology and pathogenesis", section on 'Potassium'.)

Insulin — We recommend initiating treatment with low-dose IV insulin in all patients with moderate to severe DKA or HHS who have a
serum potassium ≥3.3 mEq/L. The only indication for delaying the initiation of insulin therapy is if the serum potassium is below 3.3
mEq/L since insulin will worsen the hypokalemia by driving potassium into the cells. Patients with an initial serum potassium below 3.3
mEq/L should receive aggressive fluid and potassium replacement prior to treatment with insulin. Insulin therapy should be delayed
until the serum potassium is above 3.3 mEq/L to avoid complications such as cardiac arrhythmias, cardiac arrest, and respiratory muscle
weakness [1,19,20]. (See 'Potassium replacement' above.)

IV regular insulin and rapid-acting insulin analogs are equally effective in treating DKA [22]. The choice of IV insulin is based upon
institutional preferences, clinician experience, and cost concerns. We generally prefer regular insulin, rather than rapid-acting insulin
analogs, due to its much lower cost. For acute management of DKA or HHS, there is no role for long- or intermediate-acting insulin;
however, long-acting (glargine, detemir) or intermediate-acting (NPH) insulin is administered after recovery from ketoacidosis, prior to
discontinuation of IV insulin, to ensure adequate insulin is available when IV insulin is discontinued. In this setting, we do not use
degludec, given its 25-hour half-life and 42-hour duration of effect, as it will take at least three to four days to reach steady state [23]. In
patients with mild DKA (particularly in patients with mild DKA due to rationed or missed doses of basal insulin), intermediate- or long-
acting insulin can be administered at the initiation of treatment, along with rapid-acting insulin. (See 'Intravenous regular insulin' below
and 'Converting to subcutaneous insulin' below and 'Intravenous insulin analogs' below and 'Subcutaneous insulin regimens' below.)

Insulin therapy lowers the serum glucose concentration (by decreasing hepatic glucose production, the major effect, and enhancing
peripheral utilization, a less important effect [24]), diminishes ketone production (by reducing both lipolysis and glucagon secretion), and
may augment ketone utilization. Inhibition of lipolysis requires a much lower level of insulin than that required to reduce the serum
glucose concentration. Therefore, if the administered dose of insulin is reducing the glucose concentration, it should be more than
enough to stop ketone generation [8,24,25]. (See "Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Epidemiology
and pathogenesis", section on 'Pathogenesis'.)

Intravenous regular insulin — In HHS or moderate to severe DKA, treatment can be initiated with an IV bolus of regular insulin (0.1
units/kg body weight) followed within five minutes by a continuous infusion of regular insulin of 0.1 units/kg per hour (equivalent to 7
units/hour in a 70-kg patient) [8,26-29]. Alternatively, the bolus dose can be omitted if a higher dose of continuous IV regular insulin
:
(0.14 units/kg per hour, equivalent to 10 units/hour in a 70-kg patient) is initiated [30]. The insulin dosing is the same in DKA and HHS (
algorithm 1 and algorithm 2). The possible role of other insulin preparations is discussed below. (See 'Intravenous insulin analogs'
below and 'Subcutaneous insulin regimens' below.)

These doses of IV regular insulin usually decrease the serum glucose concentration by approximately 50 to 70 mg/dL (2.8 to 3.9 mmol/L)
per hour [24,27-29]. Higher doses do not generally produce a more prominent glucose-lowering effect, probably because the insulin
receptors are fully saturated and activated by the lower doses [26]. However, if the serum glucose does not fall by at least 50 to 70 mg/dL
(2.8 to 3.9 mmol/L) from the initial value in the first hour, check the IV access to be certain that the insulin is being delivered and that no
IV line filters that may bind insulin have been inserted into the line. After these possibilities are eliminated, the insulin infusion rate
should be doubled every hour until a steady decline in serum glucose of this magnitude is achieved.

The fall in serum glucose is the result of both insulin activity and the beneficial effects of volume repletion. Volume repletion alone can
initially reduce the serum glucose by 35 to 70 mg/dL (1.9 to 3.9 mmol/L) per hour due to the combination of ECF expansion; reduction of
plasma osmolality; increased urinary losses resulting from improved renal perfusion and glomerular filtration; and a reduction in the
levels of "stress hormones," which oppose the effects of insulin [15,28]. The serum glucose levels often fall more rapidly in patients with
HHS who are typically more volume depleted.

When the serum glucose approaches 200 mg/dL (11.1 mmol/L) in DKA or 250 to 300 mg/dL (13.9 to 16.7 mmol/L) in HHS, switch the IV
saline solution to dextrose in saline and attempt to decrease the insulin infusion rate to 0.02 to 0.05 units/kg per hour [9,11,26]. If
possible, do not allow the serum glucose at this time to fall below 200 mg/dL (11.1 mmol/L) in DKA or 250 to 300 mg/dL (13.9 to 16.7
mmol/L) in HHS, because this may promote the development of cerebral edema. (See 'Cerebral edema' below and "Diabetic ketoacidosis
in children: Cerebral injury (cerebral edema)".)

Intravenous insulin analogs — There is no advantage of rapid-acting insulin analogs over regular insulin. Intravenous regular
insulin and glulisine insulin are equally effective and equipotent for the treatment of DKA [22]. (See "General principles of insulin therapy
in diabetes mellitus", section on 'Human insulins'.)

Subcutaneous insulin regimens — Patients with mild DKA ( table 1) can be safely treated with subcutaneous, rapid-acting insulin
analogs on a general medical floor or in the emergency department but only when adequate staffing is available to carefully monitor the
patient and check capillary blood glucose with a reliable glucose meter, typically every hour.

Subcutaneous insulin protocols are being used with increasing frequency to treat selected patients with mild to moderate DKA during
the COVID-19 pandemic, when intravenous insulin may not be practical owing to the need to limit frequency of contact of staff with
patients. In this setting, dosing and monitoring is being performed every two to four hours. (See "Coronavirus disease 2019 (COVID-19):
Issues related to diabetes mellitus in adults", section on 'DKA/HHS'.)

Treatment of DKA with subcutaneous insulin has not been evaluated in severely ill patients. In mild DKA, direct comparison of
intramuscular, subcutaneous, and IV insulin therapy for hemodynamically stable DKA patients shows similar efficacy and safety [31-34].
In addition, subcutaneous administration of rapid-acting insulin analogs (eg, insulin lispro, aspart) given every one or two hours has
been demonstrated to be safe in two randomized trials in adults with uncomplicated DKA ( algorithm 1) [32,33]. In one trial, for
example, 40 patients with DKA were assigned to one of two regimens [32]:

● Subcutaneous, rapid-acting insulin lispro as an initial injection of 0.3 units/kg, followed by 0.1 units/kg every hour until the serum
glucose was less than 250 mg/dL (13.9 mmol/L). The insulin lispro dose was then decreased to 0.05 to 0.1 units/kg and administered
every one or two hours until resolution of the ketoacidosis. These patients were treated on a regular internal medicine floor or in an
intermediate care unit.

● IV regular insulin as an initial bolus of 0.1 units/kg, followed by an infusion of 0.1 units/kg per hour until the serum glucose was less
than 250 mg/dL (13.9 mmol/L). The insulin dose was then decreased to 0.05 to 0.1 units/kg per hour until resolution of the
ketoacidosis. These patients were treated in the intensive care unit.

The duration of therapy until correction of hyperglycemia and resolution of ketoacidosis was the same with both regimens (7 and 10 to
11 hours, respectively), but there was a 39 percent reduction in cost with insulin lispro, mainly related to the higher cost of treatment in
the intensive care unit.

Bicarbonate and metabolic acidosis — Although the indications for sodium bicarbonate therapy to help correct metabolic acidosis are
controversial, there are selected patients who may benefit from cautious alkali therapy [35]. They include:

● Patients with an arterial pH ≤6.9 in whom decreased cardiac contractility and vasodilatation can impair tissue perfusion [36,37]. At
an arterial pH above 7.0, most experts agree that bicarbonate therapy is not necessary since therapy with insulin and volume
:
 expansion will largely reverse the metabolic acidosis [38].

For patients with pH ≤6.9, we give 100 mEq of sodium bicarbonate in 400 mL sterile water administered over two hours. If the
serum potassium is less than 5.3 mEq/L, we add 20 mEq of KCl. When the bicarbonate concentration increases, the serum
potassium may fall and more aggressive KCl replacement may be required.

● Patients with potentially life-threatening hyperkalemia, since bicarbonate administration in acidemic patients may drive potassium
into cells, thereby lowering the serum potassium concentration. The exact potassium level that should trigger this intervention has
not been defined; we administer sodium bicarbonate if the potassium level is >6.4 mEq/L [39]. (See "Treatment and prevention of
hyperkalemia in adults".)

The venous pH and bicarbonate concentration should be monitored every two hours, and bicarbonate doses can be repeated until the
pH rises above 7.0. (See 'Monitoring' below.)

The indications for bicarbonate therapy in DKA are controversial [40], and evidence of benefit is lacking [41-43]. In a randomized trial of
21 DKA patients with an admission arterial pH between 6.90 and 7.14 (mean 7.01), bicarbonate therapy did not change morbidity or
mortality [41]. However, the study was small, limited to patients with an arterial pH 6.90 and above, and there was no difference in the
rate of rise in the arterial pH and serum bicarbonate between the bicarbonate and placebo groups. No prospective randomized trials
have been performed concerning the use of bicarbonate in DKA with pH values less than 6.90.

Bicarbonate administration is also controversial because, in addition to lack of evidence for benefit, there are several potential harmful
effects:

● If bicarbonate infusion successfully increases the blood bicarbonate concentration, this can reduce the hyperventilatory drive, which
will raise the blood partial pressure of carbon dioxide (pCO2). Increased blood carbon dioxide (CO2) tension is more quickly reflected
across the blood brain barrier than the increased arterial bicarbonate. This may cause a paradoxical fall in cerebral pH. Although
neurologic deterioration has been attributed to this mechanism, it remains a very controversial effect and, if it occurs, is rare [35].

● The administration of alkali may slow the rate of recovery of the ketosis [44,45]. In a study of seven patients, the three patients
treated with bicarbonate had a rise in serum ketoacid anion levels and a six-hour delay in resolution of ketosis [44]. Animal studies
indicate that bicarbonate infusion can accelerate ketogenesis. This is thought to be related to the fact that acidemia has a "braking
effect" on organic acid generation. This brake is lessened by any maneuver that increases systemic pH [41].

● Alkali administration can lead to a post-treatment metabolic alkalosis since metabolism of ketoacid anions with insulin results in the
generation of bicarbonate and spontaneous correction of most of the metabolic acidosis. (See "Diabetic ketoacidosis and
hyperosmolar hyperglycemic state in adults: Epidemiology and pathogenesis", section on 'Anion gap metabolic acidosis'.)

Phosphate depletion — Based upon the observations described below, we do not recommend the routine use of phosphate
replacement in the treatment of DKA or HHS. However, phosphate replacement should be strongly considered if severe
hypophosphatemia occurs (serum phosphate concentration below 1 mg/dL or 0.32 mmol/L), especially if cardiac dysfunction, hemolytic
anemia, and/or respiratory depression develop [46-50]. When needed, potassium or sodium phosphate 20 to 30 mEq can be added to 1
L of IV fluid.

Although whole-body phosphate depletion is common in uncontrolled diabetes mellitus, the serum phosphate concentration may
initially be normal or elevated due to movement of phosphate out of the cells [7,47]. Similar to potassium, phosphate depletion and
hypophosphatemia may be rapidly unmasked following the institution of insulin therapy and IV volume expansion. This frequently leads
to asymptomatic hypophosphatemia, which gradually resolves. (See "Hypophosphatemia: Clinical manifestations of phosphate
depletion".)

Prospective, randomized trials of patients with DKA have failed to show a beneficial effect of phosphate replacement on the duration of
ketoacidosis; dose of insulin required; or the rate of fall of serum glucose, morbidity, or mortality [51-53]. In addition, phosphate
replacement may have adverse effects, such as hypocalcemia and hypomagnesemia [51,54-56]. Consequently, routine replacement is
not indicated. When the patient stabilizes, phosphate-rich food such as dairy products and almonds may be recommended.

MONITORING

General — The serum glucose should initially be measured every hour until stable, while serum electrolytes, blood urea nitrogen (BUN),
creatinine, and venous pH (for DKA) should be measured every two to four hours, depending upon disease severity and the clinical
response [1,9]. The effective plasma osmolality (Posm) can be estimated from the sodium and glucose concentrations using the
:
following equations, depending upon the units for sodium (Na) and glucose:

Effective Posm = [2 x Na (mEq/L)] + [glucose (mg/dL) ÷ 18]

Effective Posm = [2 x Na (mmol/L)] + glucose (mmol/L)

The Na in these equations is the actual measured plasma sodium concentration and not the "corrected" sodium concentration.

It is strongly suggested that a flow sheet of laboratory values and clinical parameters be utilized because it allows better visualization
and evaluation of the clinical picture throughout treatment of DKA ( form 1).

Monitoring with arterial blood gases is unnecessary during the treatment of DKA; venous pH, which is approximately 0.03 units lower
than arterial pH [57], is adequate to assess the response to therapy and avoids the pain and potential complications associated with
repeated arterial punctures. If blood chemistry results are promptly available, an alternative to monitoring venous pH is to monitor the
serum bicarbonate concentration (to assess correction of the metabolic acidosis) and the serum anion gap (to assess correction of the
ketoacidemia).

Where available, bedside ketone meters that measure capillary blood beta-hydroxybutyrate are an alternative to the measurement of
electrolytes and anion gap for monitoring the response to treatment. These devices are increasingly available, reliable, and convenient
[13]. Beta-hydroxybutyrate can then be measured every two hours depending on the clinical response [58]. When bedside meters are
not available, monitoring venous pH and/or the venous bicarbonate and anion gap is sufficient.

Resolution of DKA/HHS — The hyperglycemic crisis is considered to be resolved when the following goals are reached:

● The ketoacidosis has resolved, as evidenced by normalization of the serum anion gap (less than 12 mEq/L) and, when available,
blood beta-hydroxybutyrate levels

● Patients with HHS are mentally alert and the effective plasma osmolality has fallen below 315 mOsmol/kg

● The patient is able to eat

The disappearance of ketoacid anions in the serum and correction of the ketoacidosis can be monitored by measuring venous pH, beta-
hydroxybutyrate directly, and/or serum electrolytes and bicarbonate concentrations with calculation of the serum anion gap. The serum
anion gap provides an estimate of the quantity of unmeasured anions in the plasma. It is calculated by subtracting the major measured
anions (chloride and bicarbonate) from the major measured cation (sodium). The sodium concentration used for this calculation is the
concentration reported by the laboratory not the "corrected" sodium concentration.

Accumulation of ketoacid anions (the sum of beta-hydroxybutyrate and acetoacetate) increases the anion gap above its baseline, and
the increment reflects the sum of their concentrations in serum. Monitoring the anion gap will provide a reasonable estimate of changes
in these serum ketoacid anion concentrations. The anion gap returns to the normal range when ketoacid anions have disappeared from
the serum.

Correction of the ketoacidosis can also be monitored by direct measurement of serum or capillary beta-hydroxybutyrate. Although
assessments of urinary or serum ketone levels by the nitroprusside method can be used for the initial diagnosis of ketoacidosis, it
should not be used for monitoring resolution of DKA. Nitroprusside reacts mainly with acetoacetate, to a much lesser degree with
acetone (which is not an acid), and not with beta-hydroxybutyrate. These characteristics of this test can generate clinical confusion. For
example, a positive nitroprusside test may persist for up to 36 hours after resolution of the ketoacidosis due to a positive reaction with
acetone, which is slowly eliminated, mainly via the lungs [59,60]. Since acetone is not an acid, a persistent nitroprusside reaction due to
acetone does not indicate ketoacidosis. In addition, active treatment of ketoacidosis shifts the reaction between beta-hydroxybutyrate
and acetoacetate toward acetoacetate. This may result in an increasingly positive nitroprusside test (due to higher acetoacetate
concentrations) despite an overall improvement of the ketoacidosis ( figure 1) [25].

In the absence of severe kidney disease, almost all patients develop a normal anion gap acidosis ("non-gap" or "hyperchloremic
acidosis") during the resolution phase of the ketoacidosis. This occurs because aggressive intravenous (IV) volume expansion reverses
volume contraction and improves renal function, which accelerates the loss of ketoacid anions with sodium and potassium [61,62]. The
loss of these ketoacid anion salts into the urine represent "potential" bicarbonate loss from the body. Insulin therapy will have no further
effect on the acidosis when this stage evolves. The hyperchloremic acidosis will slowly resolve as the kidneys excrete ammonium chloride
(NH4Cl) and regenerate bicarbonate.

Converting to subcutaneous insulin — For patients with DKA, we initiate a multiple-dose (basal-bolus), subcutaneous insulin schedule
when the ketoacidosis has resolved and the patient is able to eat (see 'Resolution of DKA/HHS' above). If the patient is unable to eat, it is
:
preferable to continue the IV insulin infusion. For patients with HHS, IV insulin infusion can be tapered and a multiple-dose (basal-bolus),
subcutaneous insulin schedule started when the serum glucose falls below 250 to 300 mg/dL (13.9 to 16.7 mmol/L).

The most convenient time to transition to subcutaneous insulin is before a meal. The IV insulin infusion should be continued for two to
four hours after initiating the short- or rapid-acting subcutaneous insulin because abrupt discontinuation of IV insulin acutely reduces
insulin levels and may result in recurrence of hyperglycemia and/or ketoacidosis. Basal insulin (NPH, glargine, or detemir) can be
administered either (a) at the same time as the first injection of rapid-acting insulin, or (b) earlier (for example, the previous evening),
along with a decrease in the rate of IV insulin infusion. We typically do not administer degludec as the basal insulin when transitioning
from IV insulin due to its very long half-life, and subsequently, the time it takes to reach steady state (two to three days).

For patients with known diabetes who were previously being treated with insulin, their pre-DKA or pre-HHS insulin regimen may be
restarted. For patients who are treated with continuous subcutaneous insulin infusion (insulin pump), the previous basal rate can be
resumed. However, if the IV insulin requirements are significantly higher than their usual insulin requirements, it is reasonable to
increase the basal rate temporarily.

In patients with new-onset type 1 diabetes who have presented with DKA, an initial total daily dose (TDD) of 0.5 to 0.8 units/kg units of
insulin per day is reasonable, until an optimal dose is established. Approximately 40 to 50 percent of the TDD should be given as a basal
insulin, either as once- or twice-daily U-100 glargine or detemir, or as twice-daily intermediate-acting insulin (NPH). The long-acting
insulin can be given either at bedtime or in the morning; the NPH is usually given as approximately two-thirds of the dose in the
morning and one-third at bedtime. The remainder of the TDD is given as short-acting or rapid-acting insulin, divided before meals. The
pre-meal dosing is determined by the pre-meal glucose level, meal size, and content, glucose trends (when available from CGM), as well
as activity and exercise pattern. If NPH is the basal insulin used, a mid-day (pre-lunch) rapid-acting insulin may not be necessary. Good
clinical judgment and frequent glucose assessment are vital in initiating a new insulin regimen in insulin-naive patients. Most
importantly, the regimen needs to be adjusted based on empiric results provided by glucose monitoring and responsive to individual
lifestyle patterns including eating and activity and exercise patterns. (See "General principles of insulin therapy in diabetes mellitus" and
"Management of blood glucose in adults with type 1 diabetes mellitus", section on 'Designing an MDI insulin regimen' and "Insulin
therapy in type 2 diabetes mellitus".)

COMPLICATIONS

Hypoglycemia and hypokalemia are the most common complications of the treatment of DKA and HHS. These complications have
become much less common since low-dose intravenous (IV) insulin treatment and careful monitoring of serum potassium have been
implemented [63]. Hyperglycemia may recur from interruption or discontinuation of IV insulin without adequate coverage with
subcutaneous insulin.

Cerebral edema — Cerebral edema in uncontrolled diabetes mellitus (usually DKA, with only occasional reports in HHS) is primarily a
disease of children, and almost all affected patients are younger than 20 years old [64]. Symptoms typically emerge within 12 to 24
hours of the initiation of treatment for DKA but may exist prior to the onset of therapy. Issues related to cerebral edema in DKA,
including pathogenesis, are discussed in detail separately in the pediatric section but will be briefly reviewed here. (See "Diabetic
ketoacidosis in children: Cerebral injury (cerebral edema)".)

Headache is the earliest clinical manifestation, followed by lethargy and decreased arousal. Neurologic deterioration may be rapid.
Seizures, incontinence, pupillary changes, bradycardia, and respiratory arrest can develop. Symptoms progress if brainstem herniation
occurs, and the rate of progression may be so rapid that clinically recognizable papilledema does not develop.

DKA-associated cerebral edema has a mortality rate of 20 to 40 percent [1]. Thus, careful monitoring for changes in mental or neurologic
status that would permit early identification and therapy of cerebral edema is essential.

The 2009 American Diabetes Association (ADA) guidelines on hyperglycemic crises in diabetes in adults suggested that the following
preventive measures may reduce the risk of cerebral edema in high-risk patients [1]:

● Gradual replacement of sodium and water deficits in patients who are hyperosmolar. The usual IV fluid regimen during the first few
hours of treatment is isotonic saline at a rate of 15 to 20 mL/kg lean body weight per hour (approximately 1000 mL/hour in an
average-sized person) with a maximum of <50 mL/kg in the first two to three hours ( algorithm 1 and algorithm 2).

● Dextrose should be added to the saline solution once the serum glucose levels have fallen to 200 mg/dL (11.1 mmol/L) in DKA or 250
to 300 mg/dL (13.9 to 16.7 mmol/L) in HHS. In patients with HHS, the serum glucose should be maintained at 250 to 300 mg/dL (13.9
to 16.7 mmol/L) until the hyperosmolality and mental status improve and the patient is clinically stable.
:
Data evaluating the outcome and treatment of cerebral edema in adults are not available. Recommendations for treatment are based
upon clinical judgment in the absence of scientific evidence. Case reports and small series in children suggest benefit from prompt
administration of mannitol (0.25 to 1 g/kg) and perhaps from hypertonic (3 percent) saline (5 to 10 mL/kg over 30 min) [64]. These
interventions raise the plasma osmolality (Posm) and generate an osmotic movement of water out of brain cells and a reduction in
cerebral edema.

Noncardiogenic pulmonary edema — Hypoxemia and rarely noncardiogenic pulmonary edema can complicate the treatment of DKA
[65-67]. Hypoxemia is attributed to a reduction in colloid osmotic pressure that results in increased lung water content and decreased
lung compliance [11]. Patients with DKA who are found to have a wide alveolar-arterial oxygen gradient and/or rales may be at higher
risk for the development of pulmonary edema.

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately.
(See "Society guideline links: Hyperglycemic emergencies".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are
written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about
a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond
the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade
reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients.
(You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

● Basics topics (see "Patient education: Diabetic ketoacidosis (The Basics)" and "Patient education: Hyperosmolar nonketotic coma
(The Basics)")

SUMMARY AND RECOMMENDATIONS

● The treatment of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are similar and involves correction of the
fluid and electrolyte abnormalities that are typically present, including hyperosmolality, hypovolemia, metabolic acidosis (in DKA),
and potassium depletion, and the administration of insulin ( table 3 and algorithm 1 and algorithm 2). Frequent monitoring
is essential, and underlying precipitating events should be identified and corrected. (See 'Overview and protocols' above.)

● We recommend vigorous intravenous (IV) fluid replacement to correct both hypovolemia and hyperosmolality (Grade 1A). Fluid
replacement should correct estimated deficits within the first 24 hours, with care to avoid an overly rapid reduction in the serum
osmolality. (See 'Fluid replacement' above.)

Isotonic saline should be infused as quickly as possible in patients with hypovolemic shock. In hypovolemic patients without shock
(and without heart failure), we begin with isotonic (0.9 percent) saline infused at a rate of 15 to 20 mL/kg per hour (approximately
1000 mL/hour in an average-sized person) for the first couple of hours. This is followed by one-half isotonic (0.45 percent) saline at a
rate of approximately 250 to 500 mL/hour if the serum sodium is normal or elevated; isotonic saline is continued at a rate of
approximately 250 to 500 mL/hour if hyponatremia is present. We add dextrose to the saline solution when the serum glucose
reaches 200 mg/dL (11.1 mmol/L) in DKA or 250 to 300 mg/dL (13.9 to 16.7 mmol/L) in HHS. (See 'Fluid replacement' above.)

The need for potassium repletion may influence the timing of one-half isotonic saline therapy since the addition of potassium to
isotonic saline creates a hypertonic solution that can worsen the underlying hyperosmolality. (See 'Potassium replacement' above.)

● Patients with DKA or HHS typically have a marked degree of potassium depletion due to both renal and, in some patients,
gastrointestinal losses. However, because of potassium redistribution from the cells into the extracellular fluid (ECF), the initial
serum potassium concentration is often normal or elevated, an effect that will be reversed by insulin therapy. We recommend that
replacement with IV potassium chloride (KCl) (Grade 1A) be initiated when the serum potassium concentration is ≤5.3 mEq/L.
Patients with an initial serum potassium below 3.3 mEq/L should receive aggressive fluid and potassium replacement prior to
treatment with insulin to prevent initial worsening of the hypokalemia. (See 'Potassium replacement' above.)
:
 ● We recommend initial treatment with low-dose IV insulin in all patients with moderate to severe DKA or HHS who have a serum
potassium ≥3.3 mEq/L (Grade 1B). Patients with an initial serum potassium below 3.3 mEq/L should receive aggressive fluid and
potassium replacement prior to treatment with insulin. (See 'Potassium replacement' above.)

The insulin regimen is the same in DKA and HHS. If the serum potassium is ≥3.3 mEq/L, we give a continuous IV infusion of regular
insulin at 0.14 units/kg per hour; at this dose, an initial IV bolus is not necessary. An alternative option is to administer an IV bolus
(0.1 units/kg body weight) of regular insulin, followed by a continuous infusion at a dose of 0.1 units/kg per hour. The dose is
doubled if the glucose does not fall by 50 to 70 mg/dL (2.8 to 3.9 mmol/L) in the first hour. (See 'Insulin' above.)

A cost-effective alternative to IV insulin in the initial treatment of mild DKA ( table 1) is the use of subcutaneous, rapid-acting
insulin analogs (insulin lispro, aspart, and glulisine) in selected patients in settings in which adequate monitoring can be assured.
(See 'Subcutaneous insulin regimens' above.)

● Indications for sodium bicarbonate therapy to help correct the metabolic acidosis are controversial. We suggest treatment with IV
sodium bicarbonate in patients with an arterial pH less than 6.9 (Grade 2B). (See 'Bicarbonate and metabolic acidosis' above.)

● Although whole-body phosphate depletion is usually present, we recommend not administering phosphate routinely (Grade 1A).
We suggest phosphate replacement for patients with severe hypophosphatemia (<1 mg/dL [0.32 mmol/L]), respiratory or cardiac
failure, or hemolytic anemia (Grade 2C). (See 'Phosphate depletion' above.)

● Monitoring involves hourly glucose measurement until stable and basic chemistry profile and venous pH (for DKA) every two to four
hours. The course of ketoacidemia can be assessed by direct measurement of beta-hydroxybutyrate, the major circulating ketoacid,
and/or measurement of the serum anion gap. In contrast, nitroprusside tablets or reagent sticks should not be used, because they
react with acetoacetate and acetone but not with beta-hydroxybutyrate. Acetone is biochemically neutral and does not contribute to
the ketoacidosis. (See 'Monitoring' above.)

● We initiate a multiple-dose (basal-bolus), subcutaneous insulin schedule when the ketoacidosis has resolved and the patient is able
to eat. For patients with HHS, IV insulin infusion can be tapered and a multiple-dose, subcutaneous insulin schedule started when
the serum glucose falls below 250 to 300 mg/dL (13.9 to 16.7 mmol/L). The IV insulin infusion should be continued for two to four
hours after initiating the subcutaneous insulin to avoid recurrence of hyperglycemia. (See 'Converting to subcutaneous insulin'
above.)

● Cerebral edema is rare in adults but is associated with high rates of morbidity and mortality. Possible preventive measures in high-
risk patients include gradual rather than rapid correction of fluid and sodium deficits (maximum reduction in plasma osmolality
[Posm] of 3 mOsmol/kg per hour), and maintenance of a slightly elevated serum glucose until the patient is stable. (See 'Cerebral
edema' above.)

ACKNOWLEDGMENT

The editorial staff at UpToDate would like to acknowledge Abbas Kitabchi, PhD, MD, FACP, MACE, who contributed to an earlier version of
this topic review.

Use of UpToDate is subject to the Subscription and License Agreement.

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54. Barsotti MM. Potassium phosphate and potassium chloride in the treatment of DKA. Diabetes Care 1980; 3:569.

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56. Zipf WB, Bacon GE, Spencer ML, et al. Hypocalcemia, hypomagnesemia, and transient hypoparathyroidism during therapy with
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60. Reichard GA Jr, Skutches CL, Hoeldtke RD, Owen OE. Acetone metabolism in humans during diabetic ketoacidosis. Diabetes 1986;
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61. Oh MS, Carroll HJ, Goldstein DA, Fein IA. Hyperchloremic acidosis during the recovery phase of diabetic ketosis. Ann Intern Med
1978; 89:925.

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65. Sprung CL, Rackow EC, Fein IA. Pulmonary edema; a complication of diabetic ketoacidosis. Chest 1980; 77:687.

66. Powner D, Snyder JV, Grenvik A. Altered pulmonary capillary permeability complicating recovery from diabetic ketoacidosis. Chest
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Crit Care Med 1985; 13:55.

Topic 1795 Version 41.0

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GRAPHICS

Typical laboratory characteristics of DKA and HHS*

DKA
HHS
Mild Moderate Severe

Plasma glucose (mg/dL) >250 >250 >250 >600

Plasma glucose (mmol/L) >13.9 >13.9 >13.9 >33.3

Arterial pH 7.25 to 7.30 7.00 to 7.24 <7.00 >7.30

Serum bicarbonate (mEq/L) 15 to 18 10 to <15 <10 >18

Urine ketones ¶ Positive Positive Positive Small

Serum ketones - Nitroprusside reaction Positive Positive Positive ≤ Small

Serum ketones - Enzymatic assay of beta hydroxybutyrate (normal range <0.6 3 to 4 mmol/L 4 to 8 mmol/L >8 mmol/L <0.6 mmol/L
mmol/L) Δ

Effective serum osmolality (mOsm/kg) ◊ Variable Variable Variable >320

Anion gap § >10 >12 >12 Variable

Alteration in sensoria or mental obtundation Alert Alert/drowsy Stupor/coma Stupor/coma

DKA: diabetic ketoacidosis; HHS: hyperosmolar hyperglycemic state.

* There may be considerable diagnostic overlap between DKA and HHS.
¶ Nitroprusside reaction method.
Δ Many assays for beta hydroxybutyrate can only report markedly elevated values as >6.0 mmol/L.
◊ Calculation: 2[measured Na (mEq/L)] + glucose (mg/dL)/18.
§ Calculation: (Na+) – (Cl– + HCO3–) (mEq/L).

Graphic 72111 Version 8.0

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 Typical total body deficits of water and electrolytes in diabetic ketoacidosis and hyperosmolar hyperglycemic state*

DKA HHS

Total water (L) 6 9

Water (mL/kg ¶) 100 100 to 200

Na + (mEq/kg) 7 to 10 5 to 13

Cl - (mEq/kg) 3 to 5 5 to 15

K + (mEq/kg) 3 to 5 4 to 6

PO 4 (mmol/kg) 5 to 7 3 to 7

Mg ++ (mEq/kg) 1 to 2 1 to 2

Ca ++ (mEq/kg) 1 to 2 1 to 2

DKA: diabetic ketoacidosis; HHS: hyperosmolar hyperglycemic state; Na +: sodium; Cl -: chloride; K +: potassium; PO 4 : phosphate; Mg ++: magnesium; Ca ++: calcium.
* Data are from Ennis et al (1994) and Kreisberg (1978).
¶ Per kilogram of body weight.

Graphic 76060 Version 6.0

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 Protocol for the management of adult patients with DKA

DKA diagnostic criteria: Serum glucose >250 mg/dL, arterial pH <7.3, serum bicarbonate <18 mEq/L, and at least moderate ketonuria or ketonemia. Normal laboratory values vary; check local lab n
electrolytes.

DKA: diabetic ketoacidosis; IV: intravenous; NaCl: sodium chloride; SC: subcutaneous; Na: sodium; NaHCO 3 : sodium bicarbonate; H 2 O: water; KCl: potassium chloride; HCO 3 : bicarbonate; K: potassium; BUN: blood
* After history and physical exam, obtain capillary glucose and serum or urine ketones. Begin 1 L of 0.9% NaCl over one hour, and draw arterial blood gases, complete blood count with differential, urinalysis, serum
chemistry profile, and creatinine levels STAT. Obtain electrocardiogram, chest radiograph, and specimens for bacterial cultures, as needed.
¶ Serum Na + should be corrected for hyperglycemia (for each 100 mg/dL glucose >100 mg/dL, add 2.0 mEq to sodium value for corrected serum sodium value).
Δ 100 mmol NaHCO 3 = 100 mEq NaHCO 3 .
◊ An alternative IV insulin regimen is to give a continuous intravenous infusion of regular insulin at 0.14 units/kg/hour; at this dose, an initial intravenous bolus is not necessary.
§ Please refer to the UpToDate topic on DKA for the definition of DKA resolution.
¥ This is an UpToDate clinical suggestion.

Graphic 61747 Version 12.0

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 Protocol for the management of adult patients with HHS

HHS diagnostic criteria: Serum glucose >600 mg/dL, arterial pH >7.3, serum bicarbonate >15 mEq/L, and minimal ketonuria and ketonemia. Normal laboratory values vary; check local lab
normal ranges for all electrolytes.

HHS: hyperosmolar hyperglycemic state; IV: intravenous; NaCl: sodium chloride; K: potassium; Na: sodium; BUN: blood urea nitrogen; SC: subcutaneous.
* After history and physical exam, obtain capillary glucose and serum or urine ketones (nitroprusside method). Begin 1 liter of 0.9% NaCl over one hour, and draw arterial blood gases, complete blood count
with differential, urinalysis, serum glucose, BUN, electrolytes, chemistry profile, and creatinine levels STAT. Obtain electrocardiogram, chest radiograph, and specimens for bacterial cultures, as needed.
¶ Serum Na + should be corrected for hyperglycemia (for each 100 mg/dL glucose >100 mg/dL, add 2.0 mEq to sodium value for corrected serum sodium value).
Δ An alternative IV insulin regimen is to give a continuous intravenous infusion of regular insulin at 0.14 units/kg per hour; at this dose, an initial intravenous bolus is not necessary.
◊ This is an UpToDate clinical suggestion.

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 Emergent diabetic ketoacidosis (DKA) management in adults: Rapid overview

Clinical features
DKA usually evolves rapidly over a 24-hour period.

Common, early signs of ketoacidosis include nausea, vomiting, abdominal pain, and hyperventilation. The earliest symptoms of marked hyperglycemia are polyuria, polydipsia, and
weight loss.

As hyperglycemia worsens, neurologic symptoms appear and may progress to include lethargy, focal deficits, obtundation, seizure, and coma.

Common causes of DKA include: infection; noncompliance, inappropriate adjustment, or cessation of insulin; new-onset diabetes mellitus; and myocardial ischemia.

Evaluation and laboratory findings

Assess vital signs, cardiorespiratory status, and mental status.

Assess volume status: vital signs, skin turgor, mucosa, urine output.

Obtain the following studies: serum glucose, urinalysis and urine ketones, serum electrolytes, BUN and creatinine, plasma osmolality, mixed venous blood gas, electrocardiogram; add
serum ketones if urine ketones present.

DKA is characterized by hyperglycemia, an elevated anion gap* metabolic acidosis, and ketonemia. Dehydration and potassium deficits are often severe.

Serum glucose is usually greater than 250 mg/dL (13.9 mmol/L) and less than 800 mg/dL (44.4 mmol/L). In certain instances (eg, insulin given prior to emergency department arrival), the
glucose may be only mildly elevated.

Additional testing is obtained based on clinical circumstances and may include: blood or urine cultures, lipase, chest x-ray.

Management
Stabilize the patient's airway, breathing, and circulation.

Obtain large bore IV (≥16 gauge) access; monitor using a cardiac monitor, capnography, and pulse oximetry.

Monitor serum glucose hourly, and basic electrolytes and venous pH or bicarbonate every two to four hours until the patient is stable.

Determine and treat any underlying cause of DKA (eg, pneumonia or urinary infection, myocardial ischemia).

Replete ECF volume and free water deficits:

• Give several liters of IV isotonic (0.9%) saline as rapidly as possible to patients with signs of shock.

• Give IV isotonic (0.9%) saline at 15 to 20 mL/kg per hour (ie, 1 to 1.5 L per hour for an average-sized adult), in the absence of cardiac compromise, for the first few hours to
hypovolemic patients without shock.

• After intravascular volume is restored, give one-half isotonic (0.45%) saline at 4 to 14 mL/kg per hour if the corrected serum Na+ ¶ is normal or elevated; isotonic saline is continued if
the corrected serum Na+ ¶ is reduced.

• Add dextrose to the saline solution when the serum glucose reaches ~200 mg/dL (11.1 mmol/L).

Replete potassium (K+) deficits:

• Regardless of the initial measured serum K+, patients with DKA have a large total body K+ deficit.

• If initial serum K+ is below 3.3 mEq/L, hold insulin and give potassium chloride 20 to 40 mEq/hour IV until K+ concentration is above 3.3 mEq/L; rarely, additional potassium
supplementation may be necessary to avoid life-threatening muscle weakness and cardiac arrhythmias.

• If initial serum K+ is between 3.3 and 5.3 mEq/L, give potassium chloride 20 to 30 mEq per liter IV fluid; maintain serum K+ between 4 to 5 mEq/L.

• If initial serum K+ is above 5.3 mEq/L, do not give potassium; check serum K+ every 2 hours; delay administration of potassium chloride until serum K+ has fallen to 5 to 5.2 mEq/L.

Give insulin:

• Do not give insulin if initial serum K+ is below 3.3 mEq/L; replete K+ and fluid deficit first.

• Give all patients without a serum K+ below 3.3 mEq/L regular insulin. Either of two regimens can be used: 0.1 units/kg IV bolus, then start a continuous IV infusion 0.1 units/kg per
hour; OR do not give bolus and start a continuous IV infusion at a rate of 0.14 units/kg per hour.

• If serum glucose does not fall by at least 50 to 70 mg/dL (2.8 to 3.9 mmol/L) in the first hour, double the rate of insulin infusion.

• When the serum glucose reaches 200 mg/dL (11.1 mmol/L), it may be possible to decrease the infusion rate to 0.02 to 0.05 units/kg per hour.

• Continue insulin infusion until ketoacidosis is resolved, serum glucose is below 200 mg/dL (11.1 mmol/L), and subcutaneous insulin is begun.

Give sodium bicarbonate to patients with pH below 6.90:

• If the arterial pH is below 6.90, give 100 mEq of sodium bicarbonate plus 20 mEq of potassium chloride in 400 mL sterile water over two hours; may be repeated if venous pH remains
below 7.00.

DKA: diabetic ketoacidosis; BUN: blood urea nitrogen; IV: intravenous; ECF: extracellular fluid; Na: sodium; K: potassium.
* Patients with DKA usually present with a serum anion gap greater than 20 mEq/L (normal range approximately 3 to 10 mEq/L). However, the increase in anion gap is variable, being determined
by several factors: the rate and duration of ketoacid production, the rate of metabolism of the ketoacids and their loss in the urine, and the volume of distribution of the ketoacid anions.
¶ Serum Na+ should be corrected for hyperglycemia; for each 100 mg/dL serum glucose exceeds 100 mg/dL (5.5 mmol/L), add 2 mEq to plasma Na+ for correction of Na+ value for
hyperglycemia. A calculator to determine serum Na+ corrected for hyperglycemia is available separately in UpToDate.

Graphic 57723 Version 4.0

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 Patient data flow sheet

Na +: sodium; K +: potassium; Cl –: chloride; HCO 3 –: bicarbonate; BUN: blood urea nitrogen; pO 2 : partial pressure of
oxygen; pCO 2 : partial pressure of carbon dioxide; O 2 : oxygen; NaCl: sodium chloride.
* A: alert; D: drowsy; S: stuporous; C: comatose.
¶ D: deep; S: shallow; N: normal.
Δ [2 × Na (mEq/L)] + [glucose (mg/dL) ÷ 18].

Graphic 62913 Version 3.0

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 Ketone response to treatment of diabetic ketoacidosis

Comparative data in 37 patients with diabetic ketoacidosis with regard to plasma acetoacetic acid and beta-
hydroxybutyric acid (A); ratio of acetoacetic acid to beta-hydroxybutyric acid (C); and ketone bodies (nitroprusside
reaction) in the urine (B) and plasma (D) before and during low-dose intravenous infusion of insulin for 48 hours.

Graphic 60366 Version 11.0

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Contributor Disclosures
Irl B Hirsch, MD Grant/Research/Clinical Trial Support: Medtronic [Diabetes]. Consultant/Advisory Boards: Abbott [Diabetes]; Roche [Diabetes]; Bigfoot
Biomedical [Diabetes]. Michael Emmett, MD Consultant/Advisory Boards: AstraZeneca [Hyperkalemia]. David M Nathan, MD Grant/Research/Clinical Trial
Support: Abbott [Diabetes]. Jean E Mulder, MD Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review
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