This protocol applies to patients with known diabetes mellitus who develop DKA with a blood glucose below 14 mmol/L — a presentation known as euglycaemic DKA. It includes patients currently receiving a sodium-glucose cotransporter (SGLT) inhibitor. Because the glucose is not particularly raised, the condition can be easy to overlook.
The initial euglycaemic DKA regimen — stopping the SGLT inhibitor if applicable, starting intravenous fluids and a fixed-rate insulin infusion — has been tried but failed to achieve the required biochemical response:
This escalation protocol is the defined next step when those targets are not being met.
The next step begins with confirming that the insulin infusion delivery is functioning correctly, then systematically adjusting the infusion rate to drive ketone clearance toward the target rates. The full step-by-step adjustment logic and monitoring criteria are contained in the complete protocol.
This is the development of DKA in people known to have diabetes but where the glucose is normal, or not particularly raised.
Initiate glucose 10% straight away at 125 ml/hr because the glucose is <14 mmol/L.
If blood ketone measurement is available and blood ketones are not falling by at least 0.5 mmol/L/hr, call a prescribing clinician to increase the insulin infusion rate by 1.0 unit/hr increments hourly until the ketones are falling at target rates (also check infusion).
Reduction of the blood ketone concentration by 0.5 mmol/L/hour. Increase the venous bicarbonate by 3.0 mmol/L/hour. Reduce capillary blood glucose by 3.0 mmol/L/hour.
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