endocrine / metabolic

DKA / Euglycemic DKA

Ketotic metabolic decompensation requiring fluid resuscitation, potassium-first insulin sequencing and continued insulin until ketoacidosis resolves—even when glucose is not markedly elevated.

CLINICAL ALGORITHMMedically Verified (2026-09-15)

Hyperglycemic crisis: distinguish DKA, HHS and overlap, then sequence potassium, fluids and insulin safely

Level: Controlled React algorithm

Visual bedside algorithm

Hyperglycemic crisis: distinguish DKA, HHS and overlap, then sequence potassium, fluids and insulin safely

Step 1 · Assess / decide

Define the phenotype

Glucose + beta-hydroxybutyrate
Venous pH/bicarbonate + electrolytes
Serum osmolality + mental status
Classify DKA, isolated HHS or mixed DKA/HHS

Step 2 · Treat

Fluids + potassium first

Restore volume with individualized isotonic/balanced crystalloid
Check potassium before insulin
If K+ <3.5 mmol/L: replace potassium and delay insulin

Step 3 · Treat

Insulin + dextrose

DKA/mixed DKA-HHS: DKA insulin strategy
Isolated HHS: lower-dose insulin after initial fluids
Add dextrose as glucose falls so insulin can continue until the metabolic crisis resolves
Euglycemic DKA still requires insulin to stop ketogenesis

Step 4 · Escalate / reassess

Reassess safely

DKA: ketones + pH/bicarbonate, not glucose alone
HHS: cognition, osmolality, sodium and urine output
Avoid rapid tonicity/osmolality shifts
Find and treat infection, ischemia, medication interruption or other trigger

Bedside bottom line

Never start insulin before correcting severe hypokalemia, and never declare resolution from a normalized glucose value alone.

Figure: Hyperglycemic crisis: distinguish DKA, HHS and overlap, then sequence potassium, fluids and insulin safely. This action-focused visual summarizes the linked Clinical Problem; the full problem text, evidence references and local policy remain the source of truth.(Action pathway — use the full evidence-linked problem and local protocol for clinical decisions)

Recognize

Diagnose DKA from diabetes/hyperglycemia or a compatible context plus ketonemia and metabolic acidosis. Measure beta-hydroxybutyrate directly when possible; glucose may be only mildly elevated in euglycemic DKA. Common settings include SGLT2 inhibitors, pregnancy, prolonged fasting, vomiting and partial insulin treatment.

Act now — fluids

Begin isotonic saline or balanced crystalloid with frequent reassessment of perfusion, sodium, heart/kidney function and urine output. Replace volume without assuming every patient needs the same rate or total volume.

Potassium before insulin

Check potassium before insulin. If K+ is <3.5 mmol/L, replace potassium first and delay insulin until K+ is safely above that level. If potassium is not low, start insulin while monitoring for the predictable intracellular potassium shift.

Insulin / dextrose

Resolution

Reassess trigger

Caution

Euglycemic DKA can be missed when clinicians use a high glucose threshold as a gatekeeper. Significant ketonemia plus metabolic acidosis in the right clinical setting requires DKA treatment even when glucose is near normal.

Direct evidence for this problem

1 source

guideline•2024

Hyperglycemic Crises in Adults With Diabetes: A Consensus Report ↗

Current multinational consensus for adult DKA, euglycemic DKA and mixed DKA/HHS diagnosis and treatment.

Evidence status

Review metadata not yet recorded.

Status, review dates and guideline versions appear here once editorial metadata is authored for this content.

Actionable Clinical Workflows (4)

Step-by-step ICU Processes

Acute Severe Metabolic Acidosis Evaluation

From primary disorder confirmation and Anion Gap calculation to Winter's compensation, delta ratio, and targeted source control.

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Metabolic Acidosis

From confirming the acid-base disorder to the anion-gap differential.

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Altered Consciousness

From securing the basics to categorizing structural, toxic-metabolic, infectious, and seizure-related causes.

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Hyperosmolar Hyperglycemic State: First 6 Hours

Confirm HHS vs mixed DKA/HHS → restore volume → potassium-safe insulin → controlled osmolality correction.

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Deep-Dive Topic Destinations (2)

Reference Knowledge

Diabetic Ketoacidosis (DKA)endocrine-metabolic

Pathophysiology, SGLT2i euglycemic DKA, balanced fluid resuscitation, potassium-before-insulin safety rules, dextrose addition kinetics, and subcutaneous transition.

Explore Topic →

Hyperosmolar Hyperglycemic State (HHS)endocrine-metabolic

ICU recognition and treatment of severe hyperglycemia, hyperosmolality and dehydration with careful fluid, potassium and insulin sequencing.

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