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Diabetic ketoacidosis (adult)

Start this sheet when: Adult with capillary glucose 250 mg/dL (14 mmol/L) or more, or known diabetes, with ketones 3 mmol/L or more (or urine 2+) and pH below 7.3 or bicarbonate below 15. Glucose can be normal on an SGLT2 inhibitor. Children follow the paediatric protocol.

Hospital (remembered on this device)Patient ID / UHID (not saved)Age / SexFilled by

Door dateDoor time (clock starts here)

Time since door

Targets met --Breaches 0

1.Triage, capillary glucose and ketones checked
≤ 15 min from door · Local target: bedside meter at triage
Enter door time
2.Venous gas back (pH, bicarbonate, potassium)
≤ 30 min from door · Local target: potassium is needed before insulin
Enter door time
3.IV fluid running (1 L in the first hour)
≤ 30 min from door · ADA/EASD 2024: fluids first, at once
Enter door time
4.Fixed-rate insulin 0.1 unit/kg/h started
≤ 1 h from door · ADA/EASD 2024 / NICE NG17: after potassium is known
Enter door time
5.First hourly glucose and ketone recheck
≤ 1 h from insulin start · ADA/EASD 2024: hourly glucose and ketones
Enter door time
6.Repeat venous gas with potassium
≤ 2 h from insulin start · ADA/EASD 2024: potassium every 2-4 h
Enter door time
7.10% dextrose added (glucose below 250 mg/dL)(Glucose below 250)
Record · Record only: keep the insulin running
N/AEnter door time
8.Disposition decided
Record · Admit / transfer / OT; for the length-of-stay audit
Enter door time
9.Patient left the ED
≤ 2 h from disposition decision · ED KPI: decision to departure 2 h or less
Enter door time

Bedside checklist

☐Potassium below 3.5: hold insulin and give potassium first
☐Potassium 3.5-5.5: add 40 mmol KCl to each litre; above 5.5: none
☐Keep the usual basal insulin (glargine) going under the infusion
☐Aim: ketones down 0.5/h, bicarbonate up 3/h, glucose down 50-75 mg/dL/h
☐Bicarbonate only if pH is below 7.0
☐Resolved: pH 7.3+, bicarbonate 15+, ketones below 0.6
☐Start SC basal and meal insulin 1-2 h before stopping the drip
☐Find the trigger: infection, missed insulin, MI, SGLT2 inhibitor, pregnancy

References

Targets marked “local” are suggestions: agree your own with the quality committee before auditing against them.

Bedside checklist

☐Potassium below 3.5: hold insulin and give potassium first

☐Potassium 3.5-5.5: add 40 mmol KCl to each litre; above 5.5: none

☐Keep the usual basal insulin (glargine) going under the infusion

☐Aim: ketones down 0.5/h, bicarbonate up 3/h, glucose down 50-75 mg/dL/h

☐Bicarbonate only if pH is below 7.0

☐Resolved: pH 7.3+, bicarbonate 15+, ketones below 0.6

☐Start SC basal and meal insulin 1-2 h before stopping the drip

☐Find the trigger: infection, missed insulin, MI, SGLT2 inhibitor, pregnancy