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endo.dka.core.v1

Diabetic ketoacidosis

endocrinologyacuteadultpediatricpregnancyacuteinpatient
Start encounter →Print handoutPRODUCTION

protocol.dka.adult.adA_2024.v1 + protocol.dka.pediatric.v1 are the runtime executors; manifest medications + dosing lists are not yet exposed as a structured RegimenAxis. Some manifest calculator IDs (calc_anion_gap, calc_winter, calc_sodium_correction, calc_corrected_ag) appear under the registry "calc.*" namespace (calc.anion_gap, calc.winters, calc.na_correction); verified mappings used. 2026-05-22 citation remediation — removed 3 off-topic placeholder PMIDs (an HF editorial, the POINT stroke trial, a biomass-fuel anaemia study) and replaced with live-verified anchors: 39052901 (2024 ADA/EASD/JBDS/AACE/DTS Hyperglycemic Crises Consensus) and 19564476 (Kitabchi 2009).

Entry points (5)

  • lab_abnormality
    Hyperglycemia + ketonemia + acidosis (ADA 2026 §16)
    hyperglycemia_with_ketones
  • lab_abnormality
    High anion-gap metabolic acidosis (ADA 2026 §16)
    high_anion_gap_acidosis
  • symptom
    Kussmaul respirations / fruity breath (Kitabchi 2009)
    kussmaul_breathing
  • symptom
    Polyuria + polydipsia + weight loss (ADA 2026 §16)
    polyuria_polydipsia
  • problem_list
    Known T1DM with intercurrent illness (ADA 2026 §16)
    type_1_diabetes

Required inputs (15)

  • agerequired
    demographic • used at CONTEXT
    Pediatric DKA cerebral-edema risk drives fluid rate ceiling per ISPAD 2022
  • weightrequired
    demographic • used at TREATMENT
    Insulin and fluid dosing are weight-based (0.1 U/kg/h, 15-20 mL/kg/h; ADA 2026 §16)
  • glucoserequired
    lab • used at INITIAL_WORKUP
    Diagnostic criterion + drives switch to dextrose-containing fluids when <200 mg/dL (ADA 2026 §16)
  • bhbrequired
    lab • used at INITIAL_WORKUP
    BHB ≥3.0 mmol/L is primary ketone criterion per ADA/EASD 2024 consensus
  • bicarbonaterequired
    lab • used at INITIAL_WORKUP
    Severity stratification: mild 15-18, moderate 10-14, severe <10 (ADA 2026 §16; Kitabchi 2009)
  • phrequired
    lab • used at INITIAL_WORKUP
    Severity stratification: mild 7.25-7.30, moderate 7.00-7.24, severe <7.00; bicarb only if pH <6.9 (ADA 2026 §16)
  • potassiumrequired
    lab • used at INITIAL_WORKUP
    Hold insulin if K <3.3; replete K aggressively before insulin (ADA 2026 §16; Kitabchi 2009)
  • sodiumrequired
    lab • used at INITIAL_WORKUP
    Corrected sodium for osmotic glucose effect; switch IVF to ½NS if rising (ADA 2026 §16)
  • creatininerequired
    lab • used at INITIAL_WORKUP
    Pre-renal AKI common; gates contrast and drug dosing (KDIGO 2021)
  • anion_gaprequired
    lab • used at MONITORING
    AG closure defines DKA resolution (ADA 2026 §16)
  • sglt2i_userequired
    history • used at CONTEXT
    Euglycemic DKA on SGLT2i requires dextrose + insulin regardless of glucose (ADA 2026 §16)
  • pregnancy_statusrequired
    history • used at CONTEXT
    Pregnancy mandates IV (not SC) protocol + fetal monitoring; high fetal mortality (ADA 2026 §16)
  • insulin_pump
    history • used at CONTEXT
    Pump malfunction is common precipitant (ADA 2026 §16)
  • current_meds
    medication • used at CONTEXT
    Steroids, antipsychotics, SGLT2i, recent insulin dose timing (ADA 2026 §16)
  • osmolality
    lab • used at INITIAL_WORKUP
    Effective osmolality >300 mOsm/kg flags mixed DKA-HHS overlap (JBDS 2023)

12-phase flow (12)

  1. 1FRAME
    Confirm DKA criteria (glucose, BHB ≥3.0, AG acidosis) and rule out HHS overlap, starvation/alcohol ketosis, or alternate AGMA (ADA 2026 §16)
    inputs: glucose, bhb, bicarbonate, ph
    advance: DKA criteria met per ADA/EASD 2024 consensus
  2. 2ENTRY
    Capture entry trigger (lab pattern, symptom, problem-list T1DM; ADA 2026 §16)
    inputs: age, weight
    advance: demographic + weight captured (ADA 2026 §16)
  3. 3CONTEXT
    Diabetes type/duration, insulin regimen + adherence + last dose, SGLT2i exposure, precipitant screen, pregnancy status (ADA 2026 §16)
    inputs: sglt2i_use, pregnancy_status, insulin_pump, current_meds
    advance: precipitant screen complete (ADA 2026 §16)
  4. 4RED_FLAGS
    Severe acidosis pH <7, K >6 with ECG changes, K <3.3 (no insulin until repleted per ADA 2026 §16), AMS, cerebral edema (ISPAD 2022), pregnancy, MI as precipitant
    inputs: ph, potassium, glucose
    advance: red flags screened; ICU triggered if severe (ADA 2026 §16)
  5. 5INITIAL_WORKUP
    BMP, ABG/VBG, BHB, AG, osmolality, corrected Na, urine ketones, CBC, Mg/Phos, A1c, ECG, urinalysis ± cultures, pregnancy test, autoantibodies if new-onset (ADA 2026 §16; Kitabchi 2009)
    inputs: glucose, bhb, bicarbonate, ph, potassium, sodium, creatinine, osmolality
    actions: panel.glucose_a1c, panel.abg, panel.renal, workup.dka_hhs
    advance: severity classified per ADA 2026 §16; precipitant identified or workup in flight
  6. 6BRANCHING_WORKUP
    Branch on severity (mild → SC vs IV) and overlap (HHS, AKI, pregnancy, new-onset T1DM) per ADA 2026 §16; escalate workup for precipitant (sepsis, MI, pancreatitis)
    inputs: osmolality
    advance: phenotype-specific workup queued (ADA 2026 §16)
  7. 7DIFFERENTIAL
    Exclude HHS, starvation/alcoholic ketosis, lactic/uremic acidosis, methanol/EG, salicylate, sepsis with metabolic acidosis (Kitabchi 2009; ADA 2026 §16)
    advance: differential narrowed (Kitabchi 2009)
  8. 8RISK_STRATIFICATION
    Mild (pH 7.25-7.30) / Moderate (7.00-7.24) / Severe (<7.00) per ADA 2026 §16; pediatric cerebral-edema risk score (ISPAD 2022); pregnancy risk; AKI stage (KDIGO 2021)
    inputs: ph, bicarbonate
    actions: calc.anion_gap, calc.winters, calc.na_correction, calc.ckd_epi_2021
    advance: severity + disposition class assigned (ADA 2026 §16)
  9. 9TREATMENT
    5-step protocol per ADA 2026 §16: NS 15-20 mL/kg/h → K replacement (hold insulin if <3.3) → IV insulin 0.1 U/kg/h → bicarb only if pH <6.9 → switch to D5 ½NS at glucose <200; SC lispro acceptable in mild (Kitabchi 2009); basal overlay 0.15-0.3 U/kg before stopping infusion; pregnancy = IV only; euglycemic = D10 + insulin + stop SGLT2i
    inputs: weight, glucose, potassium, ph, sglt2i_use, pregnancy_status
    actions: protocol.dka, protocol.dka_peds
    advance: fluids + insulin + K running with monitoring (ADA 2026 §16)
  10. 10DISPOSITION
    Ward (mild SC), step-down (moderate IV), ICU (severe / mixed DKA-HHS / pregnancy / pediatric / cerebral edema risk per ISPAD 2022); endocrinology consult new-onset (ADA 2026 §16)
    advance: level of care assigned (ADA 2026 §16)
  11. 11MONITORING
    Hourly glucose, BMP q1-2h until AG closes, BHB q2-4h, K with each BMP, telemetry, strict I/Os, neuro checks q1h if severe (ISPAD 2022); resolution = AG closed + BHB <1 + bicarb >18 + patient eating (ADA 2026 §16)
    inputs: anion_gap, glucose, potassium
    actions: panel.renal, panel.glucose_a1c
    advance: resolution criteria met per ADA 2026 §16; SC overlap transition planned
  12. 12FOLLOWUP
    Endo within 1 wk, PCP within 2 wk, DSME, sick-day rules, discharge insulin plan, CGM initiation per ADA 2026, psychosocial follow-up if recurrent
    advance: discharge insulin regimen documented per ADA 2026 §16; education delivered; follow-up scheduled