Guideline
DIABETES - GUIDELINE FOR THE MANAGEMENT OF DIABETIC
KETOACIDOSIS IN ADULTS.
Document Number
GE2017_028
Publication Date
17 April 2018
Intranet location/s
Clinical – Medicine - Endocrinology
Summary
Endorsed By
This guideline was developed to assist in the acute management
of adults with diabetic ketoacidosis and reduce unwarranted
clinical variation in the management of diabetic ketoacidosis
across NSLHD.
NSLHD
Diabetes Network in consultation with the
NSLHD Acute Medicine and Critical Care Network
Dr Darshika Christie-David Ph: 9998 6130
Darshika.christie-david@health.nsw.gov.au
NSLHD Diabetes Network
Sector/Service
NSLHD
Audience
Emergency Departments, Intensive Care Units, Medical wards,
Junior Medical Officers, Endocrinology and Diabetes services.
Medical, Nursing, Pharmacy
Date Created
6 March 2017
Review date
October 2022
Previous Reference
No.
GE2017_028 v.1
Related Policy/s
PR2009_362 Diabetes – Management of Hypoglycaemia
GE2009_054 Diabetic Ketoacidosis in Children and
Adolescents Clinical Guidelines for the Management NSLHD
Key Words
Diabetes, Diabetic Ketoacidosis DKA
Status
Active
Author Department
Contact (Details)
Disclaimer: This document is solely for use within Northern Sydney Local Health District and unauthorised
dissemination or modification should not take place.
NORTHERN SYDNEY LOCAL HEALTH DISTRICT
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Title: Diabetes – Guideline for the Management of Diabetic
Ketoacidosis in Adults
1. Preamble
The purpose of this guideline is to assist staff in assessing and treating adults with type 1
diabetes who present with diabetic ketoacidosis (DKA). Occasionally patients with longstanding type 2 diabetes may present with ketoacidosis (ketosis-prone type 2 diabetes)
[1]. This guideline does not apply to patients presenting with hyperglycaemic
hyperosmolar state (HHS) or children presenting with DKA.
2. Scope of Practice
Medical staff:
Assess the patient and institute fluid resuscitation and electrolyte replacement
Order intravenous insulin infusion(s) and infusion rate changes
Order biochemistry and other investigations as required
Consult with admitting physician and ensure that treatment occurs in the
appropriate setting (High Dependency Unit / Intensive Care Unit if clinically
indicated)
Registered Nurses:
Assemble infusion/s
Check IV insulin infusion / syringe driver and cannula site
Adjust insulin and hydration infusion(s) rates according to medical orders
Perform blood glucose/ketone monitoring.
Enrolled Nurses:
Check insulin infusion / syringe driver and cannula site
Perform blood glucose/ketone monitoring and report results to RN/MO
Assistants in Nursing:
Perform blood glucose/ketone monitoring and report results to RN/MO
3. Guideline
DIABETIC KETOACIDOSIS (DKA):
Ketonaemia is the hallmark of DKA. DKA typically occurs in people with type 1 diabetes
although it has been reported in people with type 2 diabetes. DKA is a medical emergency
and a patient with this condition must be admitted to hospital.
DKA may develop rapidly, however in most cases the patient has been unwell for a number
of days. DKA may develop in a patient with previously diagnosed type 1 diabetes; however, it
may be the initial presentation of type 1 diabetes.
The biochemical criteria for the diagnosis of diabetic ketoacidosis [2] include:
 Hyperglycaemia (blood glucose level > 11 mmol/L or the presence of type 1 diabetes).
AND AT LEAST ONE OF THE FOLLOWING:
 Venous pH < 7.3
 Bicarbonate < 15 mmol/L
 Capillary blood ketone level (BKL) 3.0 mmol/L
 urine ketones ++ or more
Guideline Name
Document ID
Date Published
Diabetes - Guideline for the Management of Diabetic Ketoacidosis in Adults
GE2017_028
Version No.
1
17/4/2018
Page No.
3 of 11
NORTHERN SYDNEY LOCAL HEALTH DISTRICT
The controlled version of this document appears on the intranet
Once the diagnosis of DKA is confirmed management should be supervised by the
Emergency Department senior and/or medical registrar. When formal biochemistry results
become available the patient should be discussed with an endocrinologist (if available)
otherwise the general physician on call. HDU/ICU admission should be requested.
Symptoms and assessment on presentation to the emergency department
Presenting symptoms:
Polyuria
Polydipsia
Dehydration
Abdominal pain
Vomiting
Confusion
Initial assessment:
Hydration (fluid deficit varies) \
Perfusion
Blood Pressure and Pulse
Level of consciousness/Glasgow Coma Scale (GCS)
Blood ketone level (preferred to urine ketone)
Precipitants including sepsis/infection, acute myocardial
infarction, pregnancy, omission of insulin
Complications, including DVT
• Blood ketone level (preferred to urine ketone)
• Capillary blood glucose level
 Arterial or venous blood gas – assess pH, bicarbonate,
lactate and anion gap
 Urgent laboratory BGL (Blood Glucose Meter may read
“Hi” above approximately 33.3 mmol/L)
 EUC Note: Serum sodium is factitiously reduced as a
consequence of hyperglycaemia
To correct sodium for glucose use the following formula:
Investigations at triage:
Investigations on
presentation:
Corrected sodium = measured sodium concentration + [1.6 x
(serum glucose – 5.5) / 5.5]
 FBC
 Magnesium
 Lipase
 ECG
 CXR
 Cultures including blood and urine
 CK (if concern about rhabdomyolysis)
 Troponin (if concern about acute coronary syndrome)
 Beta HCG (in women of reproductive age)
Guideline Name
Document ID
Date Published
Diabetes - Guideline for the Management of Diabetic Ketoacidosis in Adults
GE2017_028
Version No.
1
17/4/2018
Page No.
3 of 11
NORTHERN SYDNEY LOCAL HEALTH DISTRICT
The controlled version of this document appears on the intranet
Observations
Parameter
BGL
Ketones
Pulse
Blood Pressure
Level of
consciousness/GCS
Strict fluid balance
Potassium
Venous or arterial pH
Telemetry
Required Monitoring
Hourly capillary level; Hourly laboratory BGL if capillary blood
glucose meter reads ‘HI’
Hourly capillary level
Hourly for at least the first four hours
Hourly for at least the first four hours
Hourly for at least the first four hours
Hourly
Baseline level; one hour after commencement of treatment; every
one to two hours thereafter
Minimum fourth hourly
Cardiac monitoring when indicated
Note: Rapidly falling blood glucose is a risk factor for cerebral oedema.
 Glucose and ketone results should be recorded on the NSLHD Insulin Infusion
Management Chart (CHT08954).
 All Observations to be continued until acidosis and ketosis resolves/
 Two intravenous cannulae are required for patients with DKA - one for fluid
replacement, and one for insulin and glucose management (Y site). Consider
inserting an arterial line.
 it is recommended that the patient remain Nil By Mouth (NBM) until the metabolic
acidosis has resolved. Reintroduction of a fluid and/or solid diet is at the discretion of
the treating team. Intravenous fluid replacement should continue until the patient is
eating and drinking normally.
DKA MANAGEMENT PLAN
ACTION 1
Hydration
ACTION 2
Commence potassium replacement
ACTION 3
Commence insulin replacement
ACTION 4
Resume subcutaneous insulin
ACTION 1. HYDRATION
Sodium and water
Guideline Name
Document ID
Date Published
Diabetes - Guideline for the Management of Diabetic Ketoacidosis in Adults
GE2017_028
Version No.
1
17/4/2018
Page No.
3 of 11
NORTHERN SYDNEY LOCAL HEALTH DISTRICT
The controlled version of this document appears on the intranet
The immediate aim of treatment is to restore intravascular volume.Sodium chloride 0.9%
should be initially used for rehydration.
Once BGL falls below 15mmol/L, 10% glucose must be commenced at 80 mL/hr in addition
to the hydration fluid.
Suggested Regimen
Systolic Blood
Pressure (SBP) >90
mmHg give first litre
0.9% sodium
chloride over 60
minutes
SBP <90 mmHg give
500 mL 0.9% sodium
chloride over 15
minutes. If SBP
remains below 90
mmHg repeat whilst
requesting senior
input


Second litre 0.9%
sodium chloride
with 30 mmol
potassium
chloride over 2
hours
Third litre 0.9%
sodium chloride
with potassium
chloride over 2
hours.
Fourth litre 0.9%
sodium chloride
with potassium
chloride over 4
hours.
Then 1 litre
every 4-6 hours
until fluid deficit
is replaced
The initial fluid resuscitation will result in a lowering of
blood glucose levels.
Once BGL < 15 mmol/L commence 10% dextrose at
80mL/hr (ideally through a separate large bore cannula) in
addition to the hydration fluid. Adjust the infusion rate of
0.9% sodium chloride with 30mmol potassium chloride per
litre concentration, to maintain adequate rehydration.
Potassium replacement mandatory (see below)
Colloid solutions are not generally required.
CAUTION: Sodium chloride in the quantity recommended above can cause a non-anion gap
metabolic acidosis. Fluids containing less chloride (such as Hartmann’s solution) may be
considered with senior advice.
Senior advice should be sought for the following patient groups:





Young people aged 16 – 25 years (at higher risk of cerebral oedema)
Low body weight.
Elderly
Pregnant women
Presence of cardiac or respiratory disease and/or renal impairment.
Guideline Name
Document ID
Date Published
Diabetes - Guideline for the Management of Diabetic Ketoacidosis in Adults
GE2017_028
Version No.
1
18/10/2017
Page No.
3 of 11
ACTION 2. ASSESS POTASSIUM AND COMMENCE POTASSIUM
REPLACEMENT







Replace potassium (K+) as soon as serum potassium is < 5.5 mmol/L and urine output is
established.
If the initial serum potassium is less than 3.5 mmol/L potassium replacement must be
commenced prior to commencing insulin replacement. The patient must be on a cardiac
monitor.
Regular laboratory monitoring (1 – 2 hourly levels) is essential in the initial stage, then
monitor every 4 hours.
Correction of acidosis can dramatically lower potassium level.
Usual requirement for potassium is around 10 – 20 mmol/L per hour in the initial stage.
Beware of potassium replacement in the presence of oliguria or renal impairment
Use of intravenous fluids preloaded with potassium is preferred (e.g. sodium chloride
0.9% with 30 mmol potassium chloride per litre concentration)
ACTION 3. COMMENCE INSULIN REPLACEMENT
Continuation of long - acting insulin analogues (Lantus or Levemir)
Patients receiving Levemir (Detemir) or Lantus (Glargine) should continue their usual dose
(administered at the time it is usually given, typically nocte or twice daily) in conjunction with
the IV insulin infusion (see below) [2,3].
Patients not receiving long – acting insulin analogues
For patients not receiving Levemir (Detemir) or Lantus (Glargine) administer a stat dose of
insulin glargine (Lantus) at 0.2 units per kilogram at the time the IV insulin infusion is
commenced (see below). Insulin glargine (Lantus) should be continued at this dose,
administered once daily whilst the IV insulin continues.
Continuous Subcutaneous Insulin Infusion (insulin pumps)


Insulin pumps should be discontinued until the DKA has resolved. (The insulin pump is
an expensive device and should be managed according to the hospital’s policy for
storage of patient valuables).
Administer a stat dose of insulin glargine (Lantus) at 0.2 units per kilogram at the time the
insulin pump is discontinued and the IV insulin infusion is commenced (see below).
Insulin glargine (Lantus) should be continued at this dose, administered once daily whilst
the IV insulin continues.
IV Insulin Infusion
Guidelines for setting up an IV insulin infusion – see Appendix A
NB: All infusions and lines must be changed every 24 hours.
Guidelines for initial and ongoing IV insulin infusion rate



A medical officer (MO) must order the initial IV insulin infusion rate.
IV Insulin infusion should start at 0.05 - 0.1 units/kg (estimated weight) per hour (5 – 8
units/hr in the average adult).
Commence intravenous insulin infusion after 1 hour of IV fluids and once potassium is >
3.5mmol/L.
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
Aim for
1.
sustained blood glucose fall of around 3-5 mmol/L per hour. Rapid correction of
hyperglycaemia may lead to cerebral oedema.
2.
progressive resolution of ketonaemia – aim for reduction in capillary ketones at
0.5 mmol/L/hr. If capillary ketone levels are not decreasing this indicates
insufficient insulin and the IV insulin infusion rate should be increased (the rate of
intravenous 10% glucose may need to be increased to maintain safe blood
glucose levels)
Algorithm 1. DKA Infusion Algorithm. To be used initially when blood ketone
levels are > 0.5 mmol/L and /or venous pH < 7.3
Algorithm 1. DKA Infusion Algorithm
To be used ONLY in patients diagnosed with Diabetic Ketoacidosis (DKA)
Aim for reduction in capillary ketones at 0.5 mmol/L per hour – rising blood ketone levels are an
indication of insufficient insulin and the insulin infusion rate may need to be increased
Change in hourly BGL (mmol/L)
Action
If BGL decreases by
Commence 10% glucose at 125 mL/hr.
10.1 mmol/L
AND
Consult senior MO for advice – consider reducing insulin
infusion rate (not less than 0.05 units/kg/hr)
If BGL decreases by
5.1 – 10 mmol/L Commence 10% glucose at 80 mL/hr or increase 10%
glucose to 125 mL/hr.
Consult senior MO for advice
If BGL decreases by
3.0 – 5 mmol/L
No change.
Commence 10% glucose at 80 mL/hr when BGL < 15
mmol/L
If BGL decreases by
0 – 2.9 mmol/L
Increase insulin infusion by 1 unit / hour
If BGL increasing
Increase insulin infusion by 2 units / hour
This is intended as a guideline for clinicians to provide quality patient care. It is not
intended, nor should it replace individual clinical judgment



There will be individual variations in the IV insulin infusion rate required to achieve a fall
in blood ketone and blood glucose levels at the desired rate. Patients with increased
insulin resistance (e.g. obesity, sepsis, steroid therapy or previous large insulin dose) will
need a greater infusion rate than patients who are insulin sensitive. The rate of IV
insulin infusion requires ongoing assessment and review. Variations to the rates
suggested above need to be individually charted and signed by a MO.
Once BGL falls below 15 mmol/L 10% glucose must be commenced at 80 mL/hr in
addition to intravenous fluids required for rehydration and maintenance of adequate
serum potassium levels (see below). Once BGL<10 mmol/L – adjust rate of glucose to
maintain BGL 5 – 10 mmol/L.
Once the ketoacidosis has resolved (BKL < 0.5 mmol/L and venous pH > 7.3), patients
should be switched to subcutaneous insulin (see below). If an intravenous insulin infusion
is still required, switch to Algorithm 2 (Glycaemic Maintenance) on the Adult IV Insulin
Infusion Chart. Aim to maintain blood glucose levels between 5 – 10 mmol/L. and ensure
10% glucose is continued/commenced at 80 mL/hr.
Guideline Name
Document ID
Date Published
Diabetes - Guideline for the Management of Diabetic Ketoacidosis in Adults
GE2017_028
Version No.
1
18/10/2017
Page No.
3 of 11
NORTHERN SYDNEY LOCAL HEALTH DISTRICT
The controlled version of this document appears on the intranet
Algorithm 2. Glycaemic Maintenance
Algorithm 2. Glycaemic Maintenance Algorithm
To be used during periods of glycaemic maintenance
Ensure 10% Glucose at 80 mL/hr is infused in addition to intravenous insulin.
Intravenous insulin infusion can be prescribed as 50 units of Actrapid in sodium chloride
0.9% total 50mLs.
BGL
Insulin infusion (units/hr)
(mmol/L)
0.5 (Treat patient with glucose. Contact MO. Repeat BGL in 15min)
4.0
4.1– 7.0
1
7.1 – 10.0
2
10.1 – 12.0
3
12.1 – 14.0
4
> 14.1
6
This is intended as a guideline for clinicians to provide quality patient care. It is not
intended, nor should it replace individual clinical judgment
Hypoglycaemia
A BGL of 4.0 mmol/L or less indicates hypoglycaemia.
The insulin infusion should NOT be turned off to treat hypoglycaemia (refer to NSLHD
Hypoglycaemia procedure).
Treatment may include:
 Reduce rate of IV insulin infusion to 0.5 units/hour and / or increase rate of IV glucose
infusion
 Administration of 20 mL of 50% glucose as an IV bolus (MO to order)
 Oral carbohydrate / glucose if patient is able to swallow safely
 Once BGL >5 mmol/L continue insulin infusion using an adjusted glycaemic maintenance
algorithm (insulin sensitive algorithm) – consult senior MO.
Guideline Name
Document ID
Date Published
Diabetes - Guideline for the Management of Diabetic Ketoacidosis in Adults
GE2017_028
Version No.
1
18/10/2017
Page No.
Page 8 of 11
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ACTION 4. CEASING THE IV INSULIN INFUSION
Indications for cessation:


Ketoacidosis in DKA has been corrected (BGL stable at less than 10.0 mmol, capillary
ketone level stable and less than 0.5 mmol/L and venous pH >7.3).
Patient able to tolerate oral diet
Recommencing multiple daily injections (basal-bolus) insulin.
A basal-bolus subcutaneous insulin regimen consists of a long acting basal insulin once a
day e.g. Lantus (Glargine) and a short acting bolus insulin prior to meals e.g. Novorapid
(Aspart). Aim to recommence subcutaneous insulin before a meal. Bolus insulin should be
injected with the meal and the intravenous insulin infusion discontinued 30 to 60 minutes
later.
If the patient was previously on basal insulin and this was not continued during the
intravenous insulin infusion, recommence basal insulin one to two hours before the insulin
infusion is ceased. The aim is to avoid recurrence of hyperglycaemia or ketoacidosis.
A basal or long-acting insulin should always be prescribed in addition to a short/rapid
acting insulin.
A sliding scale / supplemental insulin regimen is not acceptable as a sole therapy.
Continuous Subcutaneous Insulin Infusions (Insulin Pumps) should be recommenced only
after discussion with the treating endocrinologist and /or diabetes educator.
The subcutaneous insulin regimen will be based on the patient’s treatment before DKA
developed. For a newly diagnosed patient with Type 1 diabetes contact the Endocrinology
team on call or the patient’s medical team.
BICARBONATE



Administration is usually not necessary and should only be given on the advice of an
Endocrinologist, ICU physician or Emergency Physician.
Give only when acidosis is life threatening, e.g. when pH: < 6.8, after initial fluid
resuscitation.
Potassium and magnesium should be normal prior to administration of bicarbonate
MAGNESIUM AND PHOSPHATE REPLACEMENT

Routine replacement of magnesium and phosphate is not necessary but levels should
be measured. Magnesium is usually lowest 24 hours after admission. Replace as
required.
VTE prophylaxis
Assess the need for VTE prophylaxis using the Adult Venous Thromboembolism (VTE)
Inpatient Risk Assessment form.
Guideline Name
Document ID
Date Published
Diabetes - Guideline for the Management of Diabetic Ketoacidosis in Adults
GE2017_028
Version No.
1
18/10/2017
Page No.
Page 9 of 11
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PATIENT EDUCATION


The diabetes educator should be contacted to ensure that the patient is aware of how to
prevent and/or recognise DKA.
The diabetes educator is also available to educate and support staff.
4. References
1. Umpierrez, G.E., Ketosis-prone type 2 diabetes: time to revise the classification of
diabetes. Diabetes Care, 2006. 29(12): p. 2755-7.
2. Savage, M.W., et al., Joint British Diabetes Societies guideline for the management of
diabetic ketoacidosis. (1464-5491 (Electronic)).
3. Diabetic ketoacidosis [revised 2014 Oct]. In: eTG complete [Internet]. Melbourne:
Therapeutic Guidelines Limited; 2015 Mar.
Guideline Name
Document ID
Date Published
Diabetes - Guideline for the Management of Diabetic Ketoacidosis in Adults
GE2017_028
Version No.
1
18/10/2017
Page No.
Page 10 of 11
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The controlled version of this document appears on the intranet
Appendix A:
IV INSULIN INFUSIONS
Note: The IV insulin infusion should not be piggy–backed onto a secondary line.
Equipment List







1.0
2.0
3.0
4.1
4.2
4.3
4.4
5.0
Syringe driver
50 mL Luerlock syringe & Syringe giving set
Extension set
49.5 mL sodium chloride 0.9%
50 units (0.5 ml) short or rapid acting insulin e.g. Actrapid
Additive label
Adult IV insulin infusion management chart
Nursing Action
Explain the procedure to the patient
Wash hands and assemble equipment
Two registered nurses are required to check
any IV medication
Add 50 units (0.5mL) of soluble short acting
insulin into 49.5 mL of sodium chloride 0.9%
(1 unit insulin/1mL sodium chloride 0.9% ) in
50 mL Luerlock syringe. Discard insulin
cartridge
Gently rock syringe contents
Rationale
Reassurance
Reduce risk of infection
Reduce risk of medication error
This concentration (1 unit
insulin/1mL fluid) avoids confusion
with infusion rates.
To ensure adequate mixing of
insulin
Attach completed additive label to syringe
To identify additive and time and
date of infusion. Prepare a fresh
syringe every 24 hours to reduce
the risk of insulin adsorption onto
the surface of infusion containers
and the risk of microbiological
contamination..
Allows for initial insulin adherence
Administer via syringe driver. Prime giving
set and discard the first 20mL of solution
to infusion line. Necessary to
achieve a consistent insulin /
solution infusion
Commence insulin infusion as per Two RNs are required to check
prescription provided on the NSLHD Insulin the initial insulin infusion rate
Infusion Management Chart (CHT08954)
and complete observations and infusion rate
adjustments as charted.
Guideline Name
Document ID
Date Published
Diabetes - Guideline for the Management of Diabetic Ketoacidosis in Adults
GE2017_028
Version No.
1
18/10/2017
Page No.
Page 11 of 11