DKA/HHS Treatment Algorithm

1 Syndrome
Select DKA, HHS, or mixed DKA/HHS to view diagnostic criteria.

Effective Osm = 2 × measured Na + glucose/18; total Osm = effective Osm + BUN/2.8 (mg/dL inputs).

2 Potassium
3 Glucose
Current path
Next bedside action
Choose the syndrome, potassium, and glucose.
Fluid Replacement
Initial LR: 2–4 L

Consider reduced fluid in CHF or CKD. Individualize volume and rate.
Maintenance: choose fluid, then KCl
Glucose ≥250 mg/dL

Corrected Na <140: NS or LR
Corrected Na ≥140: ½ NS
Glucose <250 mg/dL → D5-based fluid

Corrected Na <140: D5NS or D5LR
Corrected Na ≥140: D5 ½ NS
K <3.3

Add KCl
40 mEq/L
K 3.3–<5.3

Add KCl
20 mEq/L
K ≥5.3

No added KCl
Maintenance rate: 200 mL/hr
IV Insulin
K <3.0 mEq/L

Hold insulin infusion.
Replace potassium.
Start when K ≥3.0.
K ≥3.0 mEq/L

Potassium threshold met.
If K ≥5.3: no added potassium.
Start regular insulin IV: 0.1 units/kg/hr
Check glucose every hour
Avoid glucose falling >100 mg/dL per hour
Glucose ≥250

Maintain current infusion rate; reassess glucose trend.
Glucose 150–<250

Change to D5-based maintenance fluid.
Use the glucose branches below to guide insulin adjustments.
Glucose >70–<150 → decrease current rate by 50%
Glucose ≤70 → hold IV insulin


After this hold: once glucose >150, restart at 50% of the pre-hold rate
Transition to subcutaneous insulin
Continue IV insulin until DKA/HHS resolves.1–2 hours of IV/subQ overlap. Account for basal insulin already administered.
Labs & Electrolytes
Monitoring
Glucose: every hour
More frequent checks during hypoglycemia treatment.
Labs every 4 hours
Electrolytes, creatinine, phosphate,
β-hydroxybutyrate & venous pH.

HHS: also serum osmolality.
K: 2 hours after starting insulin, then every 4 hours.
Check more often if unstable or actively replacing electrolytes.
Electrolyte replacement
Phosphorus <1.5 mg/dL
Magnesium <1.5 mg/dL
Replace and recheck per hospital electrolyte guideline.
Sodium & Osmolality
Corrected Na = measured Na
+ 0.024 × (glucose − 100)
Na: mEq/L; glucose: mg/dL.
HHS / mixed
Osmolality fall: 3–8 mOsm/kg/hr
Na fall: ≤10 mEq/L per 24 hr

Resolution Criteria

DKA resolution β-hydroxybutyrate <0.6 mmol/L AND Venous pH ≥7.30 OR HCO₃ ≥18 mmol/L. Glucose ideally <200 mg/dL. AG closed x2
HHS resolution Serum osmolality <300 mOsm/kg AND Glucose <250 mg/dL AND Urine output >0.5 mL/kg/hr AND Cognitive status improved.
For mixed DKA/HHS, confirm resolution of both the ketoacidosis and hyperosmolar components before stopping IV insulin.

Basal/Bolus Insulin Calculator

Estimated TDD—
Basal insulin—
Prandial insulin—

Enter weight or home TDD.

Quick Reference
Glucose >70–<150Reduce IV insulin 50%. Continue D5 fluid; reassess if BG remains low.
Pause and restartHold at BG ≤70 or K <3.0. After a glucose hold, restart at BG >150 and K ≥3.0, at 50% of pre-hold rate.
Potassium thresholdsK <3.3: KCl 40 mEq/L; 3.3–<5.3: 20 mEq/L; ≥5.3: none. Hold insulin if K <3.0.

Diagnostic Criteria

DKA: All 3 criteria required

  • Glucose ≥200 mg/dL or known diabetes (euglycemic DKA is possible).
  • β-hydroxybutyrate ≥3 mmol/L or urine ketones ≥2+.
  • Venous pH <7.30 or HCO₃ <18 mEq/L.

HHS: All 4 criteria required

  • Glucose ≥600 mg/dL.
  • Effective osmolality >300 or total osmolality >320 mOsm/kg.
  • β-hydroxybutyrate <3 mmol/L.
  • Venous pH ≥7.30 and HCO₃ ≥15 mEq/L.

Mixed DKA/HHS presents with significant hyperglycemia and hyperosmolality accompanied by ketoacidosis.

Fluid Replacement

  • Initial resuscitation: LR 2–4 L, adjusted for volume status, CHF, or CKD.
  • Maintenance: 200 mL/hr once euvolemic, adjusting to clinical status.
  • Glucose ≥250 mg/dL: NS or LR if corrected Na <140; ½ NS if corrected Na ≥140.
  • Glucose <250 mg/dL: Add D5-containing fluids, selecting tonicity based on corrected sodium.
  • Continue dextrose-containing fluids as needed to prevent hypoglycemia while insulin is required.

IV Insulin

  • Start regular insulin at 0.1 units/kg/hr once K ≥3.0 mEq/L per institutional protocol.
  • Glucose ≥250: Maintain the current infusion rate and reassess glucose trend.
  • Glucose 150–249: Continue insulin and add D5-containing fluids.
  • Glucose 71–149: Reduce the current insulin infusion rate by 50%.
  • Glucose ≤70: Hold insulin, treat hypoglycemia, and restart at 50% of the previous rate once glucose is >150 mg/dL.
  • Continue IV insulin until metabolic resolution, adjusting dextrose delivery to avoid hypoglycemia.

Electrolytes & Monitoring

  • Potassium <3.0: Hold insulin and replace potassium until K ≥3.0 mEq/L per institutional protocol.
  • Potassium <3.3: Add KCl 40 mEq/L to maintenance fluids.
  • Potassium 3.3–<5.3: Add KCl 20 mEq/L.
  • Potassium ≥5.3: No additional KCl initially.
  • Glucose: Every hour.
  • Electrolytes, creatinine, phosphate, β-hydroxybutyrate, and venous pH: Every 4 hours.
  • Potassium: Recheck 2 hours after starting insulin, then every 4 hours, or more frequently if actively replacing.
  • HHS: Follow serum osmolality every 4 hours and avoid rapid osmotic shifts

Resolution Criteria

DKA resolution

  • β-hydroxybutyrate <0.6 mmol/L AND
  • Venous pH ≥7.30 OR HCO₃ ≥18 mEq/L.
  • Glucose ideally <200 mg/dL.
  • Institutional requirement: Anion gap closed on 2 consecutive BMPs or returned to baseline.

HHS resolution

  • Serum osmolality <300 mOsm/kg AND
  • Glucose <250 mg/dL AND
  • Urine output >0.5 mL/kg/hr AND
  • Cognitive status improved.

Transition to Subcutaneous Insulin

  • Once resolution criteria are met, calculate the subcutaneous insulin regimen using the basal/bolus calculator.
  • Administer basal insulin before discontinuing the IV infusion, allowing 1–2 hours of overlap per institutional protocol.
  • If eating: Start basal-bolus insulin with correction coverage.
  • If NPO: Continue basal insulin with correction coverage and hold scheduled prandial insulin.
References
1
Umpierrez GE, Davis GM, ElSayed NA, et al. Hyperglycemic crises in adults with diabetes: a consensus report. Diabetes Care. 2024;47(8):1257-1275. doi:10.2337/dci24-0032.
View consensus report
DKA / HHS Diagnosis & Management
2
American Diabetes Association Professional Practice Committee for Diabetes. 16. Diabetes care in the hospital: Standards of Care in Diabetes—2026. Diabetes Care. 2026;49(Suppl 1):S339-S355. doi:10.2337/dc26-S016.
View ADA guidelines
Inpatient Diabetes Management
3
Self WH, Evans CS, Jenkins CA, et al. Clinical effects of balanced crystalloids vs saline in adults with diabetic ketoacidosis: a subgroup analysis of cluster randomized clinical trials. JAMA Netw Open. 2020;3(11):e2024596. doi:10.1001/jamanetworkopen.2020.24596.
View study
IV Fluid Selection