›Add dextrose to prevent hypoglycemia while clearing ketoacidosis
›Subcutaneous insulin for mild DKA
›Rapid-acting insulin lispro or aspart
›0.3 units/kg bolus then 0.1 units/kg hourly
›Acceptable for uncomplicated mild DKA
›JAMA Network Open 2022: hospital-wide SQ protocol safe outside ICU
›Decreased ICU utilization without increased adverse events
›Requires reliable oral intake and close monitoring
›Early subcutaneous basal insulin
›Subcutaneous glargine early in treatment
›Continue home dose or initiate 0.3 units/kg
›Speeds DKA resolution and eases transition to SQ regimen
›Class I recommendation for overlap strategy at transition
›Basal insulin 2 to 4 hours before stopping IV infusion
›Prevents rebound hyperglycemia and ketoacidosis
›Potassium protocol
›K+ <3.3 mmol/l
›Hold insulin
›IV KCl 20 to 30 mEq/hr until K+ >3.3 mmol/l
›K+ 3.3 to 5.3 mmol/l
›Add 20 to 30 mEq K+ per litre of IV fluid
›Monitor every 2 hours
›K+ >5.3 mmol/l
›Hold potassium replacement
›Recheck every 2 hours
›ECG monitoring for hyperkalemia features
›Potassium monitoring frequency
›Every 2 hours during active treatment
›Hourly if abnormal values
›Continuous ECG for arrhythmia detection
Bicarbonate and phosphate
›Bicarbonate use
›Generally not recommended
›Does not improve outcomes in DKA
›May paradoxically worsen intracellular and CSF acidosis
›Consider only if pH <6.9 to 7.0 or severe hyperkalemia with hemodynamic instability
›NaHCO3 50 mEq over 2 hours if pH <6.9
›Recheck pH after infusion before repeating
›ADA Standards of Care 2026: bicarbonate not routinely recommended
›Class I recommendation against routine use
›Limited evidence for benefit even in severe cases
›Phosphate replacement
›Not routine in DKA management
›No proven clinical benefit in trials
›Consider if phosphate <0.32 mmol/l with symptoms
›Replace symptomatic severe hypophosphatemia
›Muscle weakness, hemolytic anemia, respiratory depression
›Potassium phosphate IV preferred
Transition and DKA resolution
›Resolution criteria
›All criteria required
›pH >7.3 and bicarbonate >=18 mmol/l
›Anion gap normalized
›Glucose <14 mmol/l
›Beta-hydroxybutyrate <0.5 mmol/l
›Patient tolerating oral intake
›Nausea and vomiting resolved
›Clear liquids progressing to regular diet
›Subcutaneous insulin transition
›Basal insulin 2 to 4 hours before stopping IV insulin
›Prevents rebound ketoacidosis
›Continue home regimen if well-controlled
›New or suboptimal regimen
›Start 0.5 to 0.8 units/kg/day
›Half as basal, half as prandial
›Overlap IV insulin 30 to 60 minutes after first SQ rapid-acting dose
›Prevents gap in insulin coverage
›Monitor glucose closely during transition