Tiered management of diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults and children.
Bedside management of hyperglycemic crises. See also the Endocrinology page for ADA Standards of Care and ISPAD guidelines.
DKA Diagnosis and Severity
Diagnostic criteria (all three required)
| Criterion | Threshold |
|---|
| Glucose | above 200 mg/dL or known diabetes |
| Ketones | Beta-hydroxybutyrate (BOHB) at least 3 mM, or urine ketones at least 2+ |
| Acid-base | pH below 7.3 or bicarb below 18 mM |
ADA/EASD 2024 ConsensusADA/EASD 2024 DKA/HHS Consensus · 2024 · Diabetes CareConsensus on adult diabetic ketoacidosis and hyperosmolar hyperglycemic state: no routine insulin bolus, use fixed-rate 0.1 U/kg/hr infusion, prefer lactated Ringer's.View source ↗
Severity grading
| Severity | pH | Bicarb (mM) |
|---|
| Mild | 7.25-7.30 | 15-18 |
| Moderate | 7.0-7.24 | 10-14 |
| Severe | below 7.0 | below 10 |
Pediatric thresholds (ISPAD)
| Severity | pH | Bicarb (mM) |
|---|
| Mild | 7.2-7.3 | 10-15 |
| Moderate | 7.1-7.2 | 5-10 |
| Severe | below 7.1 | below 5 |
ISPAD Guidelines
Adult DKA Management
Initial fluid resuscitation
| Phase | Fluid | Rate |
|---|
| First hour | Isotonic crystalloid (LR or NS) | 15-20 mL/kg bolus (about 1-2 L) |
| After bolus | LR or NS | 250-500 mL/hr based on volume status |
Total deficit about 100 mL/kg. Target heart rate below 100. LR preferred over NS (less hyperchloremic acidosis). IBCC DKA
Dextrose transition
When glucose falls below 250-300 mg/dL: switch to D5 1/2NS or D10 + LR at about 150-200 mL/hr. Use separate lines Y-sited. Continue insulin to clear ketones even after glucose normalizes.
Insulin
| Parameter | Recommendation |
|---|
| IV bolus | Not routinely recommended — starting drip at 0.14 U/kg/hr achieves therapeutic levels as fast as bolus + 0.1 U/kg/hr |
| Bolus reserved for | Severe hyperkalemia, severe acidosis (bicarb below 5), or pharmacy delay |
| Standard infusion rate | 0.1 U/kg/hr (max about 15 U/hr) |
| Titration goal | Drop glucose 50-70 mg/dL/hr |
Potassium
| Threshold | Action |
|---|
| K below 3.3-3.5 mEq/L | Hold insulin — replete first |
| K 3.3-5.3 mEq/L | Add 20-30 mEq KCl per liter of IVF |
| Target | K 4-5 mEq/L |
Check K every 2-4 hours.
Bicarbonate
Not routinely recommended. No benefit in DKA; may worsen hypokalemia and impair ketone clearance. Consider only if pH below 6.9 with impaired cardiac contractility (controversial; many guidelines omit entirely).
HHS Management
Diagnosis
| Criterion | Threshold |
|---|
| Glucose | above 600 mg/dL (usually much higher) |
| Effective osmolality | above 320 mOsm/kg: 2[Na] + glucose/18 |
| Ketosis | Absent — BOHB below 3 mM, pH above 7.3, bicarb at least 15 |
Mixed DKA/HHS is common.
Fluid resuscitation
Total deficit: 100-220 mL/kg (larger than DKA).
| Phase | Fluid | Rate | Goal |
|---|
| Phase 1 | Isotonic crystalloid | 1-2 L over 1-2 hours | Correct hypovolemia |
| Phase 2 | 0.45% NS | 250-500 mL/hr | Provide free water for hypertonicity |
Reduce osmolality 3-8 mOsm/kg/hr (JBDS); do not exceed 10 mOsm/kg/hr. JBDS HHS 2023JBDS HHS 2023 Guideline · 2023 · Diabet MedJoint British Diabetes Societies guideline for hyperosmolar hyperglycemic state, emphasizing fluid replacement, slower insulin initiation, and VTE prophylaxis.View source ↗
Insulin
| Parameter | Recommendation |
|---|
| When to start | Only after osmolality stops falling with fluids alone (unless ketonemia present) |
| Starting rate | 0.05 U/kg/hr (half the DKA dose) — patients are more insulin-sensitive |
| Glucose goal | Drop 40-80 mg/dL/hr |
| When to stop | When glucose approaches about 300 mg/dL |
Electrolyte repletion
| Electrolyte | Target | Notes |
|---|
| K | above 5.3 mEq/L | Repleting K is higher priority than starting IV insulin |
| Mg | High-normal | Aggressive repletion prevents Torsades if K falls |
| Phos | Replete as needed | No evidence for routine supplementation |
Check Ca, Mg, and Phos every 2-4 hours.
VTE prophylaxis
Recommended. HHS mortality is 5-15% (5-10 times higher than DKA). Osmotic diuresis, hyperviscosity, and immobility create high VTE risk. Use LMWH unless contraindicated per JBDS.
Cerebral edema (age below 40)
Risk is lower than in pediatric DKA but real. Normal mental status with chronic hypertonicity: correct slowly (at most 10 mOsm/L/day). Altered mental status suggests acute rise and can be corrected more rapidly.
Pediatric DKA
Cerebral edema — the critical difference
Incidence about 0.5-1% of pediatric DKA episodes; mortality 20-25% if it develops. Presents 4-12 hours into treatment, not at presentation.
| Warning signs | Management |
|---|
| Headache, bradycardia, hypertension, decreased O2 sat, change in neuro status | Mannitol 0.5-1 g/kg IV or 3% NaCl 5-10 mL/kg; reduce IVF rate |
Fluid caution
| Rule | Detail |
|---|
| Initial rate | at most 10-20 mL/kg over first hour |
| Deficit replacement | Over 24-48 hours |
| Total fluid limit | Not to exceed 1.5-2x maintenance |
| Maximum bolus | No bolus above 20 mL/kg unless in shock |
| Fluid type | Isotonic fluids preferred (not hypotonic) — reduces cerebral edema risk |
Insulin dosing (peds)
| Parameter | Recommendation |
|---|
| Starting rate | 0.05-0.1 U/kg/hr IV |
| Bolus | No bolus — associated with cerebral edema |
| Mild DKA | Can start at 0.05 U/kg/hr |
| Closure criteria | pH above 7.3, bicarb above 15, glucose below 200, mental status normalized |
Other pediatric differences
- Hyperchloremic non-anion-gap acidosis is common after resuscitation (not a sign of ongoing DKA)
- Check BOHB, not urine ketones (false negatives in acidic urine)
- Phosphate repletion not routine unless below 1 mg/dL
- Bicarb: not recommended — no benefit, may worsen cerebral edema
Transition to SC Insulin
Criteria for DKA closure
| Parameter | Threshold |
|---|
| Anion gap | at most 12 |
| Bicarb | at least 18 |
| Glucose | below 200 mg/dL |
| BOHB | below 0.6-1 mM |
Protocol
| Step | Detail |
|---|
| Overlap | Give SC basal insulin 1-2 hours before stopping IV insulin |
| Starting TDD | 0.5-0.8 U/kg/day (50% basal, 50% prandial) |
| Known T1D | Resume home basal insulin on day 1 of admission; overlap until IV stopped |
| Pediatric | Give glargine/detemir 2-4 hours before stopping IV; continue for 24 hours before starting home mix |
HHS transition criteria
| Parameter | Threshold |
|---|
| Osmolality | below 300 mOsm/kg |
| Hypovolemia | Corrected (UOP at least 0.5 mL/kg/hr) |
| Cognition | Back to baseline |
| Glucose | below 270 mg/dL (below 15 mM) |
Transition to basal-bolus SC insulin with overlap.
Mixed DKA/HHS
Many patients present with features of both. Use the more conservative approach:
| Feature | Follow |
|---|
| Significant ketosis + high osmolality | DKA insulin protocol (0.1 U/kg/hr) with HHS fluid goals |
| Ketonemia present | Start insulin earlier (do not wait for osmolality to fall) |
| High osmolality without ketosis | HHS protocol (fluids first, low-dose insulin) |
| Pediatric with mixed picture | Follow pediatric DKA protocol with cerebral edema precautions |
Key references