DKA and HHS Resolution Protocol

DKA or HHS, the fluid, the potassium gate on insulin, and the crossover at resolution · v1.6

  • Enter the biochemistry and the clinical picture.
  • You get a decision on whether this is ketoacidosis or a hyperosmolar state, then the work in the order the crisis demands: fluids, then potassium, then insulin.
  • Corrected sodium and effective osmolality are calculated for you, because the choice of fluid turns on them.
  • Read the potassium line before the insulin line. The pathway holds the infusion until the K⁺ is safe, and says so in the result.

  • Children and adolescents under 18, whose fluid and insulin rates follow a paediatric protocol written around the risk of cerebral oedema.
  • The illness that precipitated the crisis, which is looked for and treated alongside this pathway rather than in it.
  • The switch back to subcutaneous insulin, which belongs to the inpatient insulin pathway in this catalogue.
  • A routine bicarbonate order. The 2024 international consensus confines any use of it to a pH below 7.0, and the 2023 British joint societies guidance omits it altogether.

1. Diagnostic Triage (DKA vs. HHS)

2. Core Vitals & Electrolytes

3. Initial Resuscitation Status

Mnemonic for Order of Action: "Find Potassium Immediately"
1. Fluids (Restore perfusion first).
2. Potassium (Check levels before pushing insulin).
3. Insulin (Stop ketogenesis).

1. Clinical Caution: Premature Insulin Cessation

The "Dextrose Crossover": The infusion is stopped because the glucose has come down below 200 mg/dL, and the patient is still acidotic. It is one of the commonest errors on an Indian ward. Why it happens: the infusion is there to shut off lipolysis and clear the ketones, and the glucose falls long before that work is finished. Stop it early and ketogenesis restarts immediately. Action: when the glucose reaches 200-250 mg/dL, halve the insulin rate and add 5% or 10% Dextrose to the IV fluids. Both keep running until the anion gap closes and the pH normalises.

2. Pathophysiology: Why K⁺ Dictates Insulin

Total body potassium is profoundly depleted in DKA, through osmotic diuresis and vomiting. The serum K⁺ hides it. Acidosis drives H⁺ into the cells and K⁺ out of them, so the first reading often looks normal or even high. The caution: insulin drives that K⁺ straight back into the cells. Give it to a patient whose baseline K⁺ is < 3.3 mEq/L and the level falls further, into the range where ventricular fibrillation and respiratory muscle paralysis occur. Always restore K⁺ ≥ 3.3 before initiating insulin.

3. Illness Scripts: DKA vs. HHS vs. Euglycaemic DKA

Condition Clinical Profile & Pathophysiology Key Drivers
Classic DKA Absolute insulin deficiency. Gluc > 250, pH < 7.3, Ketones positive. Rapid onset (hours to days). Type 1 DM, Missed insulin doses, Sepsis.
HHS (Hyperosmolar) Relative insulin deficiency. Enough insulin to stop ketones, but not enough to stop gluconeogenesis. Gluc > 600, Osm > 320. Profound dehydration (9-10L deficit). Elderly Type 2 DM, infections, poor water access. Insidious onset (weeks).
Euglycaemic DKA Blood glucose is deceptively normal (< 200 mg/dL), but profound ketoacidosis is present. SGLT2 Inhibitors (Dapagliflozin/Empagliflozin) use during fasting, surgery, or acute illness. Starvation ketosis.

4. Potassium Peripheral Line Safety

Indian Ward Reality: Adding high doses of KCl (e.g., 40 mEq) to a 500 mL saline or RL bottle infused via a peripheral line frequently causes excruciating pain, phlebitis, and vein sclerosis. Maximum safe peripheral infusion rate is 10 mEq/hr (absolute max 20 mEq/hr). For aggressive replacement, a Central Venous Catheter (CVC) is mandatory.
Abbreviations CVC (Central Venous Catheter) · D10W (10% Dextrose in Water) · D5W (5% Dextrose in Water) · DKA (Diabetic Ketoacidosis) · DM (Diabetes Mellitus) · F-P-I (Fluids, Potassium, Insulin) · Gluc (Glucose) · H⁺ (Hydrogen Ion) · HHS (Hyperosmolar Hyperglycaemic State) · ICU (Intensive Care Unit) · IV (Intravenous) · K⁺ (Potassium) · KCL (Potassium Chloride) · Na⁺ (Sodium) · NaCl (Sodium Chloride) · NS (Normal Saline) · Osm (Osmolality) · RL (Ringer's Lactate) · SGLT2 (Sodium-Glucose Cotransporter-2) · SGLT2i (Sodium-Glucose Cotransporter-2 Inhibitor)
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. PMID 39052901.
  2. Joint British Diabetes Societies for Inpatient Care. The Management of Diabetic Ketoacidosis in Adults. JBDS 02, revised March 2023.
  3. Mustafa OG, Haq M, Dashora U, Castro E, Dhatariya KK. Management of Hyperosmolar Hyperglycaemic State (HHS) in Adults: an updated guideline from the Joint British Diabetes Societies for Inpatient Care Group. Diabet Med. 2023;40(3):e15005. PMID 36370077.
  4. Indian Council of Medical Research. Standard Treatment Workflow: Diabetic Ketoacidosis (ICD-10 E11.10). Department of Health Research, Ministry of Health and Family Welfare, Government of India; July 2022.
  5. Research Society for the Study of Diabetes in India. RSSDI Clinical Practice Recommendations for the Management of Type 2 Diabetes Mellitus 2022. Int J Diabetes Dev Ctries. 2022;42(Suppl 1).
  6. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009;32(7):1335-1343. PMID 19564476. [Superseded by the 2024 consensus on the bolus]
  7. Dhatariya KK, Glaser NS, Codner E, Umpierrez GE. Diabetic ketoacidosis. Nat Rev Dis Primers. 2020;6(1):40.
  8. Pannu AK, Kiran R, Kumar A, Sharda SC. Comparative study of diabetic ketoacidosis in the elderly and non-elderly patients: a nine-year experience from an academic hospital in North India. Diabetes Metab Syndr. 2023;17(12):102903. PMID 37988830.
  9. Adrogue HJ, Madias NE. Hypernatremia. N Engl J Med. 2000;342(20):1493-1499. PMID 10816188.
How to Cite This Tool

DOIhttps://doi.org/10.5281/zenodo.22401572

AMA Style:Umakanth S. DKA and HHS Resolution Protocol. Version 1.6. MEDiscuss Clinical Decision Support System. Published 2026. Accessed . https://mediscuss.org/cdss/dka-hhs. doi:10.5281/zenodo.22401572

Vancouver Style:Umakanth S. DKA and HHS Resolution Protocol [Internet]. Version 1.6. MEDiscuss.org; 2026 [cited ]. Available from: https://mediscuss.org/cdss/dka-hhs. doi:10.5281/zenodo.22401572

Disclaimer and scope
Disclaimer: This decision-support system is written for healthcare professionals. It does not substitute clinical judgment, and the treating physician retains absolute responsibility for every diagnostic, dosing and therapeutic decision. The algorithms are built on the evidence as it stands, and the evidence moves. Verify the output against your current institutional protocol, and against the patient in front of you.
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Category Acute ResuscitationProtocol
Specialties Internal Medicine, Endocrinology

Written and maintained by

Dr Shashikiran Umakanth

Last revised 24 August 2026

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