Algorithm
- ABC; IV access; fluids first — isotonic crystalloid 1 L in first hour (adult) unless shock/heart failure dictates otherwise.
- Fixed-rate IV insulin infusion 0.1 U/kg/h after fluids — do NOT give an insulin bolus (JBDS).
- When glucose <14 mmol/L: add 10% glucose and consider reducing insulin to 0.05 U/kg/h to limit hypoK/hypoglycemia (JBDS 2023).
- Potassium: replace when K+ <5.5 and urine output present; if K+ <3.5 hold insulin until replaced.
- Monitor glucose and ketones q1 h initially; seek precipitant (infection, MI, SGLT2i euglycemic DKA).
- Avoid bicarbonate unless pH <6.9 with specialist guidance; transition to subcutaneous insulin when ketoacidosis resolved.
Red flags
- • Shock, altered mental status, or severe acidosis — ICU
- • Hypokalemia before insulin — replace K+ first
- • Cerebral edema risk if over-aggressive fluid shifts
Medications by step
Step 1 — Fluids
- Sodium chloride 0.9% · i.v.
1 L IV in first hour, then 250–500 mL/h
Step 2 — Insulin
- Insulin (regular) · i.v. infusion
0.1 U/kg/h IV; consider 0.05 U/kg/h once glucose <14 mmol/L + 10% dextrose
Step 3 — Potassium
- Potassium chloride · i.v.
20–40 mmol/L in fluids per K+ level
References
- • JBDS — DKA management guidelines (2023)
Updated: Июль 2026