📈 The F-P-I Engine: This algorithm classifies the glycaemic crisis and mathematically coordinates Fluids, Potassium, and Insulin. It calculates corrected sodium and effective osmolality to guide hydration.
1. Diagnostic Triage (DKA vs. HHS)
2. Core Vitals & Electrolytes
3. Initial Resuscitation Status
Primary Diagnosis
-
-
Corrected Sodium
-mEq/L
Drives IV Fluid choice
Effective Osmolality
-mOsm/kg
Normal: 275-295
1. Fluid Strategy (F)
2. Potassium Strategy (P)
3. Insulin & Dextrose Strategy (I)
📚 Academic Pearls & Clinical Pathophysiology
💡 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 Trap: Premature Insulin Cessation
⚠ The "Dextrose Crossover": A common and dangerous error in Indian wards is stopping the IV Insulin infusion simply because the blood glucose falls below 200 mg/dL, while the patient is still acidotic. Pathophysiology: Insulin is needed to shut off lipolysis and clear ketones, not just lower glucose. If you stop insulin, ketogenesis rebounds immediately. Action: When glucose hits 200-250 mg/dL, halve the insulin rate and ADD 5% or 10% Dextrose to the IV fluids until the anion gap closes and pH normalises.
2. Pathophysiology: Why K⁺ Dictates Insulin
Total body potassium is profoundly depleted in DKA due to osmotic diuresis and vomiting. However, the serum K⁺ often looks normal or high initially because acidosis drives H⁺ into cells in exchange for K⁺ coming out. The Trap: Insulin actively drives K⁺ back into the cells. If you give insulin to a patient with a baseline K⁺ < 3.3 mEq/L, you will plunge their serum potassium to fatal levels, precipitating instant Ventricular Fibrillation or respiratory muscle paralysis. Always restore K⁺ ≥ 3.3 before initiating insulin.
3. Illness Scripts: DKA vs. HHS vs. Euglycaemic DKA
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 Hazard
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.
Indian Council of Medical Research (ICMR). Standard Treatment Workflow for Diabetic Ketoacidosis. Department of Health Research, Ministry of Health and Family Welfare, Government of India; 2023.
Research Society for the Study of Diabetes in India (RSSDI). RSSDI Clinical Practice Guidelines for the Management of Hyperglycemia in Hospitalized Patients. 2025.
Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009;32(7):1335-1343.
How to Cite This Tool
AMA Style:
Umakanth S. DKA & HHS Resolution Protocol. MEDiscuss. Published 2026. Accessed .
Vancouver Style:
Umakanth S. DKA & HHS Resolution Protocol [Internet]. MEDiscuss.org; 2026 [cited ]. Available from:
