DKA/HHS Pathway Phase 1 (Adult)

DKA Diagnostic Criteria (See page 4 for more details): Look for the Cause:
 Blood glucose >250 mg/dl (unless SGLT2 inhibitor, liver disease, pregnancy…) Infection/Inflammation (PNA, UTI, pancreatitis,
 Arterial pH <7.3 cholecystitis)
 Bicarbonate <18 mEq/L Ischemia/Infarction (myocardial, cerebral, gut)
 Anion Gap Acidosis Intoxication (EtOH, drugs)
 Moderate ketonuria or ketonemia Iatrogenic (drugs, lack of insulin)
Insulin deficiency
1. Start IV fluids (1 L of 0.9% NaCl per hr initially)
Pregnancy
2. If serum K+ is <3.3 mEq/L HOLD insulin (insulin will drop the potassium
further--> risk for cardiac arrhythmia) PREGNANCY
 Give 40 mEq/h until K ≥ 3.3 mEq/L
 Utilize OB DKA order set Phase 1
3. Initiate DKA Order Set Phase I (*In PREGNANCY utilize OB DKA order set)
4. Start insulin 0.14 units/kg/hr IV infusion (calculate dose)  When glucose reaches 200mg/dL, Initiate OB DKA Phase 2
RN will titrate per DKA protocol  Glucose goals 100-150mg/dL OB DKA Phase 2

IVF Insulin Potassium Bicarbonate

Assess need for bicarb
Initiate and continue K <3.3 mEq/L:
insulin gtt until serum
glucose reaches 250 HOLD insulin and
mg/dl. give 40mEq K per hour pH 6.9 or less pH > 6.9
until 3.3 or greater
RN will titrate per
protocol to achieve
this target. K 3.3-5.3 mEq/L: Give 100mEq bicarb No bicarb
in 1L 0.45% NaCl
Give 20-30 mEq K in
each liter of IV fluid for
a goal serum K
When sugar < 250 4-5 mEq/L
mg/dl proceed to DKA Repeat q2h until pH
Phase II is > 6.9
K > 5.3 mEq/L:
*In PREGNANCY when Consider adding K to
sugar <200 proceed to Do not replete K, these fluids as bicarb
OB DKA Phase II monitor the level q2h drives K into cells

Approved by the DKA & Glycemic Control Committee, MMC, updated 6_2021
Owners: Dr. Laura Anderson and Stacey Starbird-Richmond
 DKA/HHS Pathway Phase 2 (Adult)
Phase 2: Glucose now less than 250mg/dL
(*BS <200mg/dL in pregnancy)
Patients with euglycemic DKA, glucose less than 250, will start at phase 2

If Anion Gap has not resolved

 Transition to DKA Order Set Phase 2

 Discontinue Phase 1 insulin infusion order and DKA

nursing titration protocol from phase 1.

 Change to fixed dose insulin infusion at suggested

rate of 2.5 units/hr (Adjust as needed for individual
patient with typical dose range of 0.02 to 0.05
units/kg/hr based on drip rate and response in
phase 1). Do not discontinue insulin therapy.

 Start dextrose containing IV fluid such as D5 ½ NS

and adjust dextrose to goal blood sugar 150-200.
(*100-150mg/dL IN PREGNANCY)

 Continue to check labs regularly.

 Reevaluate for underlying causes and consider

undetected stressor/ illness.

Refer Intranet> Search Glycemic> Select Diabetes (Glycemic Control) Program: IV Insulin or IV to SC Insulin Transition for further guidance.

*Normal Anion Gap at MMC is 5-16 meq/L for the typical patient.
Approved by the DKA & Glycemic Control Committee, MMC, updated 6_2021
Owners: Dr. Laura Anderson and Stacey Starbird-Richmond
 DKA/HHS Pathway Phase 3 (Adult)
Phase 3: If starting subcutaneous (SC) insulin, the insulin drip must overlap
with the SC basal insulin for two hours

Non-ICU Patients When Anion Gap Has Critical Illness (ICU)

Normalized
Desire to Change to
Yes
continue IV Inpatient IV
insulin? Insulin Protocol

No
RN will titrate
Consider total daily dose
Insulin Naïve? Yes of 0.5 u/kg with 50%
Insulin using
IIP calculator.
given as basal.

No
Discontinue D5
infusion if/when
Previously Yes Consider resuming appropriate.
Under Good home basal/prandial
Control? regimen.

No Advance diet
when able/
appropriate, and
if eating add
Use past 6 hours of drip Overlap IV infusion for prandial insulin.
2 hours with basal dose.
rate in phase 1 to estimate
daily basal requirement.
Order correctional insulin
Reduce by 20% for
safety. Order prandial and carb coverage.
insulin.
Advance diet as tolerated.

Refer Intranet> Search Glycemic> Select Diabetes (Glycemic Control) Program: IV Insulin or IV to SC Insulin Transition for further guidance.
Approved by the DKA & Glycemic Control Committee, MMC, updated 6_2021
*Normal Anion Gap at MMC is 5-16 meq/L for the typical patient.
Owners: Dr. Laura Anderson and Stacey Starbird-Richmond
 DKA vs HHS
Mild Moderate Severe HHS
Plasma
> 250 > 250 > 250 >600
Glucose (mg/dl)
Arterial pH 7.25 – 7.30 7.00 – 7.24 < 7.00 >7.30
Serum
Bicarbonate 15 to 18 10 to < 15 < 10 > 18
(meq/l)
Urine Ketones Positive Positive Positive Small
Serum Ketones Positive Positive Positive Small
Serum
Variable Variable Variable >320
Osmolarity
High Normal to
Anion Gap* Elevated Elevated Variable
Elevated
Change in Variable to
Alert Alert/Drowsy Stupor/Coma
Mental Status Stupor/Coma

HHS = Hyperosmolar Hyperglycemic State

DKA = Diabetic Ketoacidosis
Severe DKA with pH less than 7 and bicarbonate less than 10 may warrant treatment with bicarbonate
*With the exception of euglycemic DKA
**Normal Anion Gap at MMC is 5-16 meq/L for the typical patient

Approved by the DKA & Glycemic Control Committee, MMC, updated 6_2021
Owners: Dr. Laura Anderson and Stacey Starbird-Richmond
 Considerations in DKA: Diet and Electrolytes
Diet: Patients should be NPO until their blood glucose is < 250mg/dl, their anion gap has
normalized, and they are feeling well enough to eat. At that point, add prandial insulin to cover
carbohydrate intake.

Hypokalemia: For patients with significant hypokalemia (K< 3.3 meq/l), INSULIN MUST BE HELD
until the K is 3.3 or greater. Patients must have q1h potassium checks throughout phase 1.

Hypernatremia: Most patients presenting with DKA are mildly hyponatremic because
hyperglycemia leads to a dilutional effect. Occasionally patients may present with significant
hypernatremia, particularly those with HHS. This reflects significant volume depletion and must
be repleted with isotonic fluids (NS or LR). LR is preferred with large volumes as NS can drop the
bicarb. Once adequately resuscitated in the acute phase, ½ NS or other hypotonic fluid should be
used to address free water depletion (see phase 1 algorithm).

Patients with significant hyperglycemia at presentation may experience a rise in serum sodium
with treatment. This is expected and due to osmotic shifts that occur with reduction in
hyperglycemia. For a patient with significant hypernatremia on presentation, serum sodium falls
early on during treatment, and carries risk for cerebral edema. These patients must be monitored
closely.

Hypophosphatemia: Body stores of phosphate are significantly depleted in DKA. Nonetheless,

most patients with DKA, will not require phosphate repletion. Severe hypophosphatemia (≤1
mmol/dl) however, can be a medical emergency. These should be treated with IV phosphate
repletion and monitored on telemetry. Periodic measurement of phosphate levels during the
initial treatment of DKA is reasonable.
Approved by the DKA & Glycemic Control Committee, MMC, updated 6_2021
Owners: Dr. Laura Anderson and Stacey Starbird-Richmond
 Considerations in DKA

BG Monitoring/Insulin Infusion Titration: All patients in DKA/HHS must have hourly

blood glucose monitoring while on an insulin infusion. The Nova Meter bedside
glucometer has been approved for use in DKA with a BG range of 10-600mg/dL and is
preferable due to more rapid results. If the BG is > 600mg/dL, an hourly venous lab BG
must be obtained. Do not follow both venous and glucometer readings simultaneously.

Phase 1: The desired rate of BG decrease is approximately 50-75mg/dl per hour. Adjust
the insulin infusion based on guidelines in the DKA phase 1 protocol. Additional doses
of subcutaneous insulin are discouraged.

Phase 2: Once the glucose has dropped to less than 250mg/dl, phase 1 is complete.
Patients who continue to have an elevated anion gap (>16 meq/l) due to ongoing
ketoacidosis (and not another etiology), should continue on IV insulin therapy until the
gap has closed (phase 2). Continue hourly BG monitoring and keep NPO. In order to
avoid hypoglycemia, add a dextrose infusion for a target range of 150-200 mg/dl. The
rate and concentration of dextrose should be adjusted as needed, but most
importantly, the IV insulin should not be discontinued. The typical insulin dose range in
Phase 2 is 0.02 to 0.05 U/kg per hour, and 2.5 units per hour is a suggested infusion rate
for most patients.

Approved by the DKA & Glycemic Control Committee, MMC, updated 6_2021
Owners: Dr. Laura Anderson and Stacey Starbird-Richmond
 Considerations in DKA

Phase 3: Once DKA is resolved with a normal anion gap, add a diet and transition
the patient to SC basal, prandial & correctional insulin. Long-acting SC insulin
should overlap with the insulin infusion overlap for two hours.

Certain patients who are critically ill and will remain NPO (pre-op, bowel
obstruction, etc), may benefit from continuing on an insulin drip after DKA has
resolved. In this case, transition to the Insulin Infusion order set.

Euglycemic DKA: Patients with hepatic dysfunction, malnutrition, pregnancy, or on

SGLT2 inhibitors may on occasion present with only mild hyperglycemia (BG < 250
mg/dl), but a marked anion gap elevation from significant ketoacidosis. These
patients should be started in phase 2 of the DKA protocol.

Pregnancy: Pregnancy warrants tighter control. Initiate the OB DKA Phase 1 until
BG 200mg/dL, then maintain BG 100-150mg/dL on IV insulin utilizing OB DKA
Phase 2 until anion gap normalized.

Approved by the DKA & Glycemic Control Committee, MMC, updated 6_2021
Owners: Dr. Laura Anderson and Stacey Starbird-Richmond