DKA management hub

Workflow checklist

1. 1

   Volume resuscitation & fluid plan

   Start here. If the patient is in shock, deliver 10–30 mL/kg isotonic crystalloid increments up to 90 mL/kg (dog) / 60 mL/kg (cat) until hemodynamically stable. Then transition to the rehydration + maintenance + ongoing-losses combined rate for the active phase, dropping to maintenance + ongoing losses post-rehydration.

   Fluid choice: buffered isotonic crystalloid (LRS, Plasma-Lyte, Normosol-R) preferred over 0.9% NaCl in most DKA cases, faster acidosis resolution, less hyperchloremia, small K contribution that blunts post-insulin K decline.

   Open fluid therapy calculator →
2. 2

   Initial labs & workup

   While fluids are running, complete the diagnostic workup that distinguishes DKA from uncomplicated diabetes and identifies concurrent illness:

   • CBC, full chemistry, urinalysis with culture
   • Venous blood gas (pH, HCO₃⁻, lactate, base excess)
   • Urine ketones and/or β-hydroxybutyrate (handheld meter or quantitative)
   • Abdominal ultrasound (more sensitive than radiographs for concurrent disease)
   • cPLI / fPLI if pancreatitis is suspected
   • Endocrine workup as indicated (LDDT for hyperadrenocorticism in dogs)

   Establish baseline electrolytes before any insulin. Even apparently normal serum K can be misleading, acidosis shifts K extracellularly and total body K is usually depleted.

3. 3

   Potassium supplementation

   Most DKA patients need K supplementation from the start of fluid therapy, even with apparently normal serum K, total-body K is usually low and insulin will drop serum K further. Start a KCl CRI per the published sliding scale before or concurrent with insulin.

   Hard ceiling: 0.5 mEq/kg/hr total K delivery without continuous ECG. This ceiling applies to the SUM of K from all sources. KCl CRI plus any K from KPhos (see step 5).

   Open hypokalemia / KCl calculator →
4. 4

   Insulin therapy

   Start insulin once volume is restored and K is at least 3.5 mEq/L (or being actively supplemented). Two protocols are acceptable; choose based on local logistics and patient stability:

   • IV CRI with a sliding-scale tier table: finer titration, smoother pharmacokinetics, requires a syringe pump and stable IV access. Default for critically ill or unstable patients.
   • Intermittent IM, dosed by the BG drop in the previous hour: works without a pump, but hourly dose adjustments and more BG-curve volatility. Practical for smaller hospitals or unstable IV access.

   Use regular crystalline insulin only. Goal: lower BG by 50–75 mg/dL/hr to < 250. SC insulin is not appropriate in dehydrated DKA patients (unreliable absorption).

   Insulin CRI → Insulin IM intermittent →
5. 5

   Phosphate supplementation

   Hypophosphatemia affects ≈48% of dogs after starting DKA therapy (insulin shifts P intracellularly). Severe hypophosphatemia causes acute hemolysis, respiratory weakness, and cardiac dysfunction, the most life-threatening complication of DKA management. Check P every 4–12 hours; supplement per the sliding scale.

   Critical interaction: KPhos delivers ≈4.4 mEq K per mL alongside the phosphate. The K from KPhos counts toward the 0.5 mEq/kg/hr ceiling . REDUCE the concurrent KCl rate accordingly. The hypophosphatemia calculator surfaces this explicitly.

   Open hypophosphatemia / KPhos calculator →
6. 6

   Magnesium supplementation

   Hypomagnesemia commonly worsens after starting DKA therapy. Mg deficiency can also drive refractory hypocalcemia and hypokalemia, if K won't correct despite adequate replacement, check Mg. Supplement per the sliding scale.

   Open hypomagnesemia / MgSO4 calculator →
7. 7

   Bicarbonate (rarely needed)

   Most DKA patients do not need bicarbonate therapy. The metabolic acidosis resolves as ketones clear with insulin. Bicarbonate is considered only for severe acidosis (pH < 7.0) that has not improved after one hour of fluid therapy. Half-correction is the standard approach:

   NaHCO₃ (mEq) = 0.3 × weight (kg) × base deficit × 0.5

   Routine bicarbonate use worsens hypokalemia, causes paradoxical CSF acidosis, and decreases tissue oxygen delivery. Reserve for the truly severe acidemic case. Recheck pH every 1–4 hours during therapy.

8. 8

   Monitoring during therapy

   • Volume / hydration status every 2–6 hours
   • Body weight every 4–8 hours
   • PCV / TP every 12 hours
   • Electrolytes (K) every 4–6 hours initially
   • Phosphorus and magnesium 1–2 times daily
   • Blood glucose every 1–2 hours during insulin (or continuous interstitial monitor)
   • Venous blood gas every 4–6 hours initially
   • Continuous ECG if dyskalemia is severe
   • CBC and chemistry daily
9. 9

   Transition to maintenance

   Continue IV insulin (CRI or intermittent IM) until the patient is reliably eating, drinking, hydrated, and ketone-negative. Then transition to twice-daily SC administration of an intermediate or long-acting insulin (NPH or lente in dogs; glargine, detemir, or PZI in cats), along with a dietary change (high-fiber for dogs; high-protein, low-carbohydrate for cats). Overlap the first SC dose with the IV protocol for several hours as the longer-acting insulin reaches steady state.