Adult DKA / HHS

FLUIDS · POTASSIUM RULES · THEN INSULIN

BASIC OVERVIEW — FOLLOW YOUR LOCAL DKA PROTOCOL. This page is orientation and the sequencing rules, not an order set. Where it and your department’s DKA protocol disagree, the protocol wins.
Clinically reviewed 2026-08-18 — Lon Setnik; moved here from the Codes tool per #176, because this is a workup you read, not a card you grab in a code.

1 · CONFIRM & START FLUIDS

DKA: glucose > 250 + pH < 7.3 / HCO₃ < 18 + ketones. HHS: glucose often > 600, minimal ketosis, osmolality > 320, worse dehydration — same skeleton, gentler pace.
1 L balanced crystalloid (LR) in the first hour, then 250–500 mL/h titrated to perfusion; corrected sodium guides later tonicity.
Hunt the trigger while the fluids run: infection, ischemia, missed insulin, new pump failure.

2 · POTASSIUM RULES — THIS PAGE’S REASON TO EXIST

K < 3.3: HOLD insulin. Replace potassium first (20–40 mEq/h with monitoring) — insulin now can arrest them.
K 3.3–5.2: add 20–30 mEq potassium to each liter and start insulin.
K > 5.2: no potassium yet; start insulin; recheck K every 2 h — it will fall fast.

The sequencing error is the harmful one. Every other number on this page can be a little wrong and the patient still gets better. Insulin before the potassium is known is the one that kills.

3 · INSULIN & THE FINISH LINE

Regular insulin 0.1 u/kg/h IV infusion (bolus optional and skippable). Target a glucose fall of 50–75 mg/dL/h.
Glucose < 250 → add D5 to the fluids, do not stop the insulin — the drip treats the ketoacid, the dextrose treats the number. Stop only when the gap is closed and the patient is eating (overlap subcutaneous long-acting by 2 h).
HHS: slower correction, bigger fluid debt, higher thrombosis risk.
Young DKA patient with headache or altered mental status during treatment = cerebral edema until proven otherwise.

Sources: ADA/EASD consensus on the management of hyperglycemic crises in adults (Diabetes Care 2024) and the preceding ADA consensus statement (Diabetes Care 2009;32:1335); SQuID protocol context (Ann Emerg Med 2023) for mild DKA. — Personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.