• Continue background long acting insulin
• If patient on once daily long acting continue at their usual dose and time
• If patient on twice daily long acting continue at their usual dose and time
• If patient on twice daily MIXED insulin please continue at usual time but give 60% of normal dose units, and give as INSULATARD NOT their normal mixed insulin
• Ensure Potassium replacement (see DKA protocol)
• Look for the cause
• Think infection, significant vascular event or other stressor, insulin omission, new medicines (particularly steroids)
• ALWAYS check for pregnancy in women of childbearing age
• Remember High WCC in DKA can be related simply to the acidosis and may not be an indicator of infection.

• Glucose not falling
• Check IV access is working
• Check infusions running and correct fluids/ infusion being given
• Consider replacing existing infusions with freshly made infusions
• Discuss with a senior and consider increasing the rate of insulin infusion
• Ketones not falling
• Particularly a problem in euglycaemic ketoacidosis
• Increase the rate or concentration of IV dextrose to allow the rate of insulin infusing to be increased. Discuss with a senior before enacting this.

• The DKA protocol can be stopped if the patient is eating normally, capillary ketones are <0.6, Glucose is <14mmol/L, acidosis has resolved and bicarbonate is >16.
• If the patient is biochemically ready to stop the DKA protocol but is not eating normally then change them onto a variable rate insulin infusion (VRII).
• When stopping any IV insulin protocol, ensure the patient has their usual insulin at a mealtime and stop the IV insulin at least 30minutes afterwards.
• All patients with DKA should be discussed with the diabetes team prior to discharge.
• if treating for euglycaemic DKA please see euglycaemic DKA section.

• Euglycaemic DKA is seen when someone who is taking an SGLT2 inhibitor (SGLT2i) is unwell and has not stopped their SGLT2i, pregnancy, starvation, chronic liver disease, surgery.
• STOP the SGLT2i and do not restart unless specifically discussed and agreed with the Diabetes team.
• Use the normal DKA protocol. HOWEVER, Insulin at a minimum rate of 3 units per hours is needed to clear the ketosis. As many of these people are euglycaemic or minimally hyperglycaemic, you may need to give extra glucose (often minimum 10% dextrose) to keep insulin infusion running. Please contact the diabetes team on call if you have ANY CONCERNS regarding this.
• In euglycaemic DKA caused by SGLT2i, ketones can take an especially long time to clear. Do not stop the DKA protocol until capillary ketones <0.6 for at least 6 hours, glucose is <14 mmol/L and acidosis has resolved with bicarbonate >16. Once DKA protocol has stopped, please check ketones every 2 hours for 8 hours and then 4 hours for the next 16 hours. If ketones rise please start a VRII and contact the diabetes team immediately for further advice.
• Please contact the diabetes team on call if initial management is not successful or if there are any concerns.

For any pregnant women with DKA, please contact the diabetes and obstetric registrar on call immediately, this is a medical and obstetric emergency.

Any person under the age of 16 who presents with DKA must be discussed urgently with the Paediatric Registrar on Call and transferred to the Childrens Hospital