University of Gondar Department of Internal Medicine

Management Protocol of DKA

I. Diagnose DKA
1. Symptoms and signs (polydipsia, polyuria, abdominal pain, nausea, vomiting,
dehydration, acidotic breathing)
2. Random blood sugar >250mg/dL
3. Urine ketone present
II. Grade severity of DKA: Patient in shock, change in mentation, deep and labored
breathing => severe DKA => start intravenous fluid bolus and admit to the ICU
III. Initial work up: electrolytes, RFT, HCO3-, CBC, ESR
IV. Work up for precipitating factors: infection (urine microscopy, CXR, BF), suspected
MI=> ECG
V. Start management
1. IV fluids: 20ml/kg/hr (1-1.5L) of NS in the 1st hr. Then if patient still has signs of
dehydration continue NS at 500-100ml/hr until patient is euvolemic. Once patient is
euvolemic continue with ½ NS or NS at 200-250 ml/hr. When RBS <250mg/dL use D5W
in ½ NS or DNS. IV fluids should continue until acidosis resolves and the patient starts to
takes PO. (NB. The aim is to correct estimated deficits in 24 hrs, guided by the V/S and
input/output measurement)
2. Insulin: initial loading dose of 0.2U/kg of regular insulin IV followed by every hourly
0.1U/kg of IV push. Check the RBS every 02 hrs and if the rate of drop is < 50mg/dL/hr
(or 100mg/dl in 02 hrs), increase the insulin dose to 0.15U/kg. When RBS <200mg/dL
decrease insulin dose to 0.025- 0.05U/kg/hr until patient is out of DKA to Keep the RBS
b/n 150-200mg/dl.
3. Potassium: if patient has urine output >50ml/hr after fluid bolus administer 20-30meq
of KCL in each liter of fluid: aim is to keep K+ between 4-5 meq/L. If K+ measurement is
available and initial K+ <3.3 meq/L do not start insulin and administer 20-30meq of
KCL/hr until K+ >3.3 meq/L. If K+ >5.2 meq/L, do not administer K+ and check the K+
every 02 hrs until it is < 5.2 meq/L to start supplementation.
4. Follow Up: V/S every 01 hr, urine ketone and RBS at least every 02 hrs, calculate the
input output and net balance with the V/S. (Use the flow sheet below)
5. Patient should be NPO until acidosis resolves.
6. When RBS <200 mg/dL, urine ketone is free and patient can take PO=> acidosis resolved
(if HCO3- measurement is available, it should be >15 meq/L or anion gap ≤12meq/l) =>
stop IV fluids, start subcutaneous intermediate acting insulin, continue the intravenous
regular insulin for 02 hrs after starting the subcutaneous. Previously diabetic patients
can be put on their previous dose. New patients should start intermediate acting

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University of Gondar Department of Internal Medicine

subcutaneous insulin at a dose of 0.6 U/kg with 2/3rd in the morning and 1/3rd in the
evening. The dose should be titrated in the following days.
7. Manage identified precipitating factors
8. Proper comprehensive diabetic education and linkage to diabetic clinic prior to
discharge.

FLOW SHEET
Urine Urine Insulin
Date Time BP PR Temp RBS glucose ketone GCS dose Input Output Signature

Prepared by Dr Ermias Shenkutie