DKA / HHS Treatment
Adult hyperglycemic crisis evaluation and initial management.
Presentation
Known diabetes
Allows recognition of euglycemic DKA when glucose is below 200 mg/dL
Weight
kg
Glucose
mg/dL
Measured sodium
mEq/L
Potassium
mEq/L
Bicarbonate
mmol/L
Venous pH
β-hydroxybutyrate
Preferred measurement of ketonemia
mmol/L
BUN
Used to calculate total serum osmolality
mg/dL
Mental status
Used with acid-base severity to help classify DKA
High risk of fluid overload
Significant heart failure, ESKD, frailty, or similar volume-sensitive state
Calculated Values
Corrected Na
—
Effective Osm
—
Total Osm
—
Transition to SubQ Insulin
Use after DKA/HHS has resolved and the patient is ready to transition off IV insulin.
Home basal insulin
Optional. Enter if the patient was previously taking basal insulin.
units
Estimated total daily dose
Editable weight-based starting estimate
Weight-based TDD
—
Basal insulin
—
Approximately 50% of calculated TDD. Adjust for prior regimen, nutritional intake, renal function, and hypoglycemia risk.
Prandial insulin
—
Remaining approximately 50% of TDD divided across meals when eating.
Give basal insulin before discontinuing the IV insulin infusion. Maintain approximately 1–2 hours of overlap.
Diagnostic Criteria
DKA
Diabetes / glucose
Glucose ≥200 mg/dL or prior history of diabetes
Ketosis
β-hydroxybutyrate ≥3.0 mmol/L
Acidosis
pH <7.30 and/or bicarbonate <18 mmol/L
HHS
Glucose
≥600 mg/dL
Hyperosmolality
Effective osmolality >300 or total osmolality >320 mOsm/kg
Ketones
β-hydroxybutyrate <3.0 mmol/L
Acid-base
pH ≥7.30 and bicarbonate ≥15 mmol/L
DKA Severity
Mild
pH >7.25 to <7.30 or bicarbonate 15–18 mmol/L. Usually alert.
Moderate
pH 7.00–7.25 or bicarbonate 10 to <15 mmol/L. Alert or drowsy.
Severe
pH <7.00, bicarbonate <10 mmol/L, β-hydroxybutyrate >6 mmol/L, or severe mental status impairment.
Resolution Criteria
DKA
Ketones
β-hydroxybutyrate <0.6 mmol/L
Acid-base
Venous pH ≥7.30 or bicarbonate ≥18 mmol/L
Glucose
Ideally <200 mg/dL
Do not use anion gap alone to determine DKA resolution. Hyperchloremic non-gap acidosis is common during treatment.
HHS
Osmolality
<300 mOsm/kg
Glucose
<250 mg/dL
Clinical
Cognitive status improved and urine output >0.5 mL/kg/hr
Monitoring
Glucose
Every 1–2 hours during active treatment
DKA labs
Electrolytes, creatinine, phosphate, β-hydroxybutyrate, and venous pH approximately every 4 hours
Potassium
Recheck 2 hours after insulin initiation and approximately every 4 hours thereafter
HHS
Follow serum osmolality approximately every 4 hours