Case of the Month #37 Diabetic Ketoacidosis

Published 16/03/2023

How would you manage this patient with Diabetic Ketoacidosis ?

An ABCDE approach to assessment and resuscitation should be considered.  

The three pillars of treating DKA are: 

  1. Intravenous fluids (to restore fluid deficit) 

  1. Insulin (to stop ketogenesis) 

  1. Electrolyte correction (to correct numerous derangements and prevent arrythmias) 

The management of DKA is often supported with the use of local guidelines. One example is outlined below: 

  1. Intravenous fluids 

  • Resuscitation fluid (if systolic BP<90 mmHg) 500 ml 0.9% sodium chloride over 10–15 min. Repeated if necessary. 

  • An example of replacement fluid (once systolic BP >90 mmHg) might include: 

    • 0.9% sodium chloride 1L over 1h 
    • 0.9% sodium chloride 1L with KCL over 2 h 
    • 0.9% sodium chloride 1L with KCL over 2 h 
    • 0.9% sodium chloride 1L with KCL over 4 h 
    • 0.9% sodium chloride 1L with KCL over 4 h 
    • 0.9% sodium chloride 1L with KCL over 6 h 
  • If the blood glucose level falls below 14 mmol/L, then 10% glucose should be given at a rate of 125 ml/h alongside the 0.9% sodium chloride 

  • The insulin infusion should not be stopped (as it is required to switch off ketone production) 

  • Bicarbonate is not routinely recommended to correct metabolic acidosis (which usually resolves with adequate fluid and insulin therapy) 

  1. Insulin 

  • Fixed rate insulin infusion (FRIII) is recommended at the rate of 0.1 unit/kg/hr. An initial bolus dose of insulin is no longer recommended. 

  • If the blood ketone levels do not fall by at least 0.5 mmol/L/hour the infusion rate should be increased by 1 unit/hour increments until ketones are falling at the target rate 

  • If the patient usually takes long-acting subcutaneous insulin this should be continued at the usual dose and time 

  1. Electrolyte replacement 

  • Potassium imbalance is more common during DKA management: regular monitoring is mandatory 

Potassium levels (mmol/L) 

Potassium replacement  

Over 5.5 


3.5 – 5.5  

40 mmol/l 

Below 3.5 

Senior review as additional potassium needs to be given