DKA Management Protocol

ICU/Emergency Department

Diagnostic Criteria — DKA Triad

D
Hyperglycemia
Blood Glucose >250 mg/dL
(13.9 mmol/L)
*Euglycemic DKA: BG <250 with SGLT2i use
K
Ketosis
Serum ketones >3 mmol/L
or Urine ketones ≥2+
β-hydroxybutyrate >3.0 mmol/L preferred
A
Acidosis
pH <7.3 or HCO₃ <18 mEq/L
AG >12
Anion Gap = Na⁺ - (Cl⁻ + HCO₃⁻)

Severity Classification (ADA 2024)

Parameter Mild Moderate Severe
Arterial pH 7.25–7.30 7.00–7.24 <7.00
Serum HCO₃ (mEq/L) 15–18 10–14.9 <10
Anion Gap >10 >12 >12
Mental Status Alert Alert/Drowsy Stupor/Coma
Urine Ketones Positive Positive Positive
Serum Osmolality Variable Variable >320 mOsm/kg

Precipitating Factors — "The 5 I's"

Infection
UTI, Pneumonia, Sepsis, COVID-19
Insulin
Non-compliance, Pump failure, New-onset T1DM
Infarction
MI, CVA, Mesenteric ischemia
Intoxication
Alcohol, Cocaine, SGLT2 inhibitors
Iatrogenic
Steroids, Thiazides, Atypical antipsychotics

Initial Workup (Time 0)

Laboratory

  • ABG/VBG (pH, pCO₂, HCO₃)
  • BMP (Na⁺, K⁺, Cl⁻, BUN, Cr, Glucose)
  • Serum ketones (β-hydroxybutyrate)
  • Serum osmolality (calculated + measured)
  • CBC with differential
  • Phosphate, Magnesium, Calcium
  • Lactate, LFTs, Lipase
  • HbA1c (if new diagnosis)
  • Urinalysis + Culture, Blood cultures

Calculated Values

Corrected Na⁺:
Na⁺ + 1.6 × [(Glucose - 100) / 100]
Anion Gap:
Na⁺ - (Cl⁻ + HCO₃⁻) → Normal: 8–12
Effective Osmolality:
2×Na⁺ + Glucose/18 → Normal: 275–295
Delta-Delta (Δ/Δ):
ΔAG / ΔHCO₃ → Mixed disorder if <1 or >2

Imaging & Other

  • ECG (hyperkalemia, MI)
  • CXR (infection, pulmonary edema)
  • Foley catheter (strict I/O)