Clinical Scenario
DKA — JBDS bundle
DIAGNOSIS
Glucose >11 (or known diabetes), ketones ≥3 mmol/L (or ≥2+ urine), pH <7.3 or bicarbonate <15.
INITIAL
- A–E. 0.9% saline 1 L over 1 h (caution if SBP <90 — bolus 500 mL and reassess), then 1 L over 2 h, 2 h, 4 h, 4 h, 6 h.
- Fixed-rate insulin infusion 0.1 unit/kg/h with patient's long-acting analogue continued.
- Add 10% dextrose when glucose <14.
MONITORING
- Hourly capillary glucose and ketones
- VBG at 2 h, 4 h, 8 h, 12 h, 24 h. Target ketone fall ≥0.5 mmol/L/h, bicarbonate rise ≥3 mmol/L/h, glucose fall 3 mmol/L/h. If not met, increase insulin by 1 unit/h.
POTASSIUM REPLACEMENT
- K >5.5 → none. - K 3.5–5.5 → 40 mmol/L. - K <3.5 → hold insulin, replace via central line in HDU.
ESCALATION
- HDU for pH <7.0, GCS drop, K <3.5 or >6.0, hypotension, oligo-anuria, pregnancy.
- Transition to subcutaneous insulin only when biochemically resolved (ketones <0.6, pH >7.3, eating) — overlap by 1 hour with long-acting analogue.