DKA & HHS Resolution Protocol • MEDiscuss

DKA & HHS Resolution Protocol v1.0 Dynamic Fluid, Potassium & Insulin Synthesis Engine

📈 The Three Pillars: This engine mathematically coordinates Fluid Resuscitation, Potassium Replacement, and Insulin Titration. It automatically calculates corrected sodium and intercepts premature insulin cessation.

1 Patient Baseline & Vitals

Weight (kg)

Clinical Diagnosis

Severe Hypovolaemia / Cardiogenic Shock (MAP < 65 mmHg)

2 Laboratory Biomarkers

Plasma Glucose (mg/dL)

Serum Potassium (mEq/L)

Measured Sodium (mEq/L)

Arterial/Venous pH (Opt)

📚 Protocol Architecture & Clinical Traps

⚠ The Lethal Potassium Trap
Total body potassium is profoundly depleted in DKA, even if the initial serum measurement appears normal or high (due to acidemia driving K⁺ out of cells). Initiating an IV insulin drip violently drives potassium back into the intracellular space. If serum K⁺ is < 3.3 mEq/L, starting insulin will trigger catastrophic, fatal hypokalaemia (respiratory paralysis, cardiac arrest). You MUST hold insulin and aggressively replace potassium first.

Pseudo-Hyponatraemia & Corrected Sodium

Hyperglycaemia raises serum osmolality, pulling intracellular water into the extracellular space and artificially diluting the serum sodium concentration.
Formula: Corrected Na⁺ = Measured Na⁺ + 1.6 × [(Glucose - 100) / 100]
Always use the corrected sodium to guide your fluid choice. Using uncorrected sodium will cause you to erroneously administer 0.9% NaCl, leading to hyperchloraemic metabolic acidosis, which artificially masks the resolution of the anion gap.

The Dextrose Clamp (Preventing Premature Cessation)

A classic error is stopping the insulin drip the moment blood glucose drops below 200 mg/dL. This instantly halts the suppression of ketogenesis, plunging the patient back into DKA. When glucose hits 200 mg/dL, you must add 5% Dextrose (D5W) to the IV fluids and halve the insulin drip rate. You are now “clamping” the glucose while keeping the insulin running to chemically clear the ketones.

Criteria for Resolution & SC Transition

DKA Resolution: Blood glucose < 200 mg/dL AND two of the following: Serum bicarbonate ≥ 15 mEq/L, venous pH > 7.30, calculated anion gap ≤ 12 mEq/L.
HHS Resolution: Normal osmolality and recovery of normal mental status.
Transition Protocol: You MUST administer the first dose of subcutaneous basal insulin 1 to 2 hours BEFORE stopping the IV insulin infusion to prevent rebound ketoacidosis.

Abbreviations: DKA (Diabetic Ketoacidosis) · HHS (Hyperosmolar Hyperglycaemic State) · NS (Normal Saline) · D5W (5% Dextrose in Water) · K⁺ (Potassium) · Na⁺ (Sodium)

⚠ Clinical Disclaimer: This algorithm is a clinical decision aid based on ADA guidelines. It does not replace clinical judgement. Patients with DKA/HHS require continuous critical care monitoring, strict fluid intake/output measurement, and laboratory draws (glucose hourly, electrolytes Q2-4H).

DKA & HHS Resolution Protocol — Clinical decision support for educational purposes. Unauthorised reproduction, redistribution, or modification of this tool is prohibited. For permissions, contact mediscuss.org/contact.

Algorithm References & Evidence Base

American Diabetes Association. Standards of Medical Care in Diabetes—2025. Diabetes Care. 2025;48(Suppl 1).
Kitabchi AE, et al. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009;32(7):1335-1343.
Fayfman M, et al. Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State. Med Clin North Am. 2017;101(3):587-606.

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