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endo.dka.core.v1PRODUCTION
endo.dka.core.v1

Diabetic ketoacidosis

endocrinologyacuteadultpediatricpregnancy
Hard-required inputs
0 / 12
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm DKA criteria (glucose, BHB ≥3.0, AG acidosis) and rule out HHS overlap, starvation/alcohol ketosis, or alternate AGMA (ADA 2026 §16)

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Actions
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Advance rule
Set
Advance when

DKA criteria met per ADA/EASD 2024 consensus

Patient inputs (15)

Pediatric DKA cerebral-edema risk drives fluid rate ceiling per ISPAD 2022

Euglycemic DKA on SGLT2i requires dextrose + insulin regardless of glucose (ADA 2026 §16)

Pregnancy mandates IV (not SC) protocol + fetal monitoring; high fetal mortality (ADA 2026 §16)

Diagnostic criterion + drives switch to dextrose-containing fluids when <200 mg/dL (ADA 2026 §16)

BHB ≥3.0 mmol/L is primary ketone criterion per ADA/EASD 2024 consensus

Severity stratification: mild 15-18, moderate 10-14, severe <10 (ADA 2026 §16; Kitabchi 2009)

Severity stratification: mild 7.25-7.30, moderate 7.00-7.24, severe <7.00; bicarb only if pH <6.9 (ADA 2026 §16)

Hold insulin if K <3.3; replete K aggressively before insulin (ADA 2026 §16; Kitabchi 2009)

Corrected sodium for osmotic glucose effect; switch IVF to ½NS if rising (ADA 2026 §16)

Pre-renal AKI common; gates contrast and drug dosing (KDIGO 2021)

AG closure defines DKA resolution (ADA 2026 §16)

Insulin and fluid dosing are weight-based (0.1 U/kg/h, 15-20 mL/kg/h; ADA 2026 §16)

Pump malfunction is common precipitant (ADA 2026 §16)

Steroids, antipsychotics, SGLT2i, recent insulin dose timing (ADA 2026 §16)

Effective osmolality >300 mOsm/kg flags mixed DKA-HHS overlap (JBDS 2023)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (11)

11 need judgement
  • informationallife_threateningpediatric_cerebral_edema — ISPAD 2022
    Pediatric DKA with new headache, bradycardia, hypertension, AMS, or focal neuro signs (ISPAD 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpregnancy_dka — ADA 2026 §16
    DKA in pregnancy (any trimester; ADA 2026 §16)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverek_lt_3_3_hold_insulin — ADA 2026 §16
    Serum K <3.3 mEq/L on initial labs (ADA 2026 §16)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereph_lt_6_9_bicarb — ADA 2026 §16
    Arterial/venous pH <6.9 — adult only (ADA 2026 §16)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereeuglycemic_sglt2i_dka — ADA 2026 §16
    Euglycemic DKA on SGLT2i (glucose <250 with AGMA + ketones; ADA 2026 §16)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverenew_onset_t1dm_at_dka — ADA 2026 §14
    First-presentation DKA without prior diabetes diagnosis OR known T1DM <12 months from diagnosis with antibody-positive serology (ADA 2026 §14)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereinsulin_pump_failure_dka — ADA 2026 §16
    Documented or suspected insulin pump occlusion/site failure (rapid-onset DKA <8h since last bolus) in pump user (ADA 2026 §16)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremixed_dka_hhs_overlap — ADA/EASD 2024
    BHB ≥3.0 + effective osmolality >320 + pH <7.30 (mixed DKA-HHS, ~30% of presentations; ADA/EASD 2024 consensus)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateglucose_lt_200_add_dextrose — ADA 2026 §16
    Glucose <200–250 mg/dL while AG still open (ADA 2026 §16)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateflatbush_ketosis_prone_t2dm — Diabetes Care 2013
    DKA presentation in older / overweight / African-American or Hispanic patient with negative autoantibodies + preserved C-peptide (ketosis-prone T2DM / Flatbush diabetes; Diabetes Care 2013)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildgap_closure_transition — ADA 2026 §16
    AG ≤12, BHB <1, bicarb >18, patient eating (ADA 2026 §16)
    Trigger could not be auto-evaluated — needs clinician judgement.

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RISK_STRATIFICATIONrequiredDrives severity classification
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Recommended regimen

DKA acute resuscitation — ADA/EASD 2024 5-pillar (fluids → K → insulin → bicarb → transition)
axis: dka_acute_5pillarstep 1 - Pillar 1 — Volume resuscitation
Selected step "Pillar 1 — Volume resuscitation" — Hemodynamic instability or volume depletion (almost universal at presentation; ADA 2026 §16)
  • 0.9% sodium chloride
    first line
    crystalloid
    Adult 1.0–1.5 L IV bolus over 1h, then 250–500 mL/h; ISPAD peds 10 mL/kg over 30–60 min only if shocked, total ≤40 mL/kg first 4h • IV • continuous
    triggers: hypovolemia, hypotension
    ADA/EASD 2024 — restore volume + GFR; switch to ½NS if corrected Na rising; peds slower per ISPAD 2022 to limit cerebral-edema risk
    rxcui 9863
  • dextrose 5% in 0.45% NaCl
    add on
    maintenance_dextrose_fluid
    D5 ½NS at 150–250 mL/h once glucose <200–250 mg/dL (ADA 2026 §16) • IV • continuous
    triggers: glucose_lt_200, euglycemic_DKA
    Allows insulin to keep clearing ketones without iatrogenic hypoglycemia; mandatory in euglycemic / SGLT2i-DKA from outset (ADA 2026 §16)
    rxcui 4850

ed playbook — drug actions (5)

  1. 1. 0.9% NaCl bolus
    Adult 1.0–1.5 L IV over 1h; peds 10 mL/kg over 30–60 min only if shocked • IV • over 1h
    trigger: DKA confirmed + volume depletion
    ADA 2024 / ISPAD 2022
  2. 2. KCl
    K<3.3: 20–40 mEq/h IV; K 3.3–5.2: 20–30 mEq/L in fluids; K>5.2: hold (ADA 2026 §16) • IV • continuous in fluids
    trigger: K result back
    Insulin contraindicated until K ≥3.3 (ADA 2026 §16; Kitabchi 2009)
  3. 3. regular insulin IV
    0.1 U/kg/h infusion; NO bolus (ADA 2026 §16) • IV • continuous
    trigger: K ≥3.3 + fluids running
    ADA 2020 — bolus offers no benefit
  4. 4. D5 ½NS
    150–250 mL/h • IV • continuous
    trigger: Glucose <200–250 OR euglycemic DKA from outset (ADA 2026 §16)
    Permits insulin to clear ketones without hypoglycemia (ADA 2026 §16)
  5. 5. sodium bicarbonate 100 mmol
    100 mmol in 400 mL water + 20 mEq KCl over 2h • IV • q2h until pH ≥7.0
    trigger: pH <6.9 (adult only)
    ADA 2024; never in peds

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Hyperglycemia + ketonemia + acidosis (ADA 2026 §16); High anion-gap metabolic acidosis (ADA 2026 §16); Kussmaul respirations / fruity breath (Kitabchi 2009).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Diabetic ketoacidosis** (endo.dka.core.v1).
Phenotype framing: Exclude HHS, starvation/alcoholic ketosis, lactic/uremic acidosis, methanol/EG, salicylate, sepsis with metabolic acidosis (Kitabchi 2009; ADA 2026 §16)
Scope: Confirm DKA criteria (glucose, BHB ≥3.0, AG acidosis) and rule out HHS overlap, starvation/alcohol ketosis, or alternate AGMA (ADA 2026 §16)

No severity triggers fired against current inputs.

Plan

Regimen axis: **DKA acute resuscitation — ADA/EASD 2024 5-pillar (fluids → K → insulin → bicarb → transition)** — step "Pillar 1 — Volume resuscitation".
1. 0.9% sodium chloride Adult 1.0–1.5 L IV bolus over 1h, then 250–500 mL/h; ISPAD peds 10 mL/kg over 30–60 min only if shocked, total ≤40 mL/kg first 4h IV continuous (crystalloid, first line) — ADA/EASD 2024 — restore volume + GFR; switch to ½NS if corrected Na rising; peds slower per ISPAD 2022 to limit cerebral-edema risk
2. dextrose 5% in 0.45% NaCl D5 ½NS at 150–250 mL/h once glucose <200–250 mg/dL (ADA 2026 §16) IV continuous (maintenance_dextrose_fluid, add on) — Allows insulin to keep clearing ketones without iatrogenic hypoglycemia; mandatory in euglycemic / SGLT2i-DKA from outset (ADA 2026 §16)

Setting playbook (ed) — Confirm DKA per ADA 2026 §16, classify severity, initiate 5-pillar resuscitation, decide ward vs step-down vs ICU before transfer
3. 0.9% NaCl bolus Adult 1.0–1.5 L IV over 1h; peds 10 mL/kg over 30–60 min only if shocked IV over 1h — DKA confirmed + volume depletion (ADA 2024 / ISPAD 2022)
4. KCl K<3.3: 20–40 mEq/h IV; K 3.3–5.2: 20–30 mEq/L in fluids; K>5.2: hold (ADA 2026 §16) IV continuous in fluids — K result back (Insulin contraindicated until K ≥3.3 (ADA 2026 §16; Kitabchi 2009))
5. regular insulin IV 0.1 U/kg/h infusion; NO bolus (ADA 2026 §16) IV continuous — K ≥3.3 + fluids running (ADA 2020 — bolus offers no benefit)
6. D5 ½NS 150–250 mL/h IV continuous — Glucose <200–250 OR euglycemic DKA from outset (ADA 2026 §16) (Permits insulin to clear ketones without hypoglycemia (ADA 2026 §16))
7. sodium bicarbonate 100 mmol 100 mmol in 400 mL water + 20 mEq KCl over 2h IV q2h until pH ≥7.0 — pH <6.9 (adult only) (ADA 2024; never in peds)

Non-pharmacologic actions:
- Foley + strict I/Os if obtunded or volume titration uncertain (JBDS 2023)
- NG tube only if vomiting + AMS at risk for aspiration (Dhatariya 2020)
- Cardiac monitor for hyperkalemia + ICU triage (ADA 2026 §16)
- Pediatric: 2-bag system to titrate dextrose without changing rate (ISPAD 2022)

AVOID / contraindication checks:
- Hold_insulin_if_K_lt_3_3 — ADA 2026 §16
- No_bicarb_in_peds_dka — ISPAD 2022
- Peds_fluids_max_40_mlkg_first_4h — ISPAD 2022
- Overlap_basal_2h_before_stopping_IV_insulin — ADA 2024
- Euglycemic_DKA_continue_insulin_with_dextrose_stop_SGLT2i — ADA 2026 §16
- No_routine_phosphate_repletion — ADA 2026 §16

Monitoring

Regimen monitoring:
- glucose q1h — ADA 2026 §16
- BMP q2 4h until AG closed — ADA 2026 §16
- BHB q2 4h — JBDS 2023
- K with each BMP — ADA 2026 §16
- pH q2h if severe — ADA 2026 §16
- fluid balance strict IO — JBDS 2023
- neuro checks q1h peds for cerebral edema — ISPAD 2022
- telemetry — ADA 2026 §16

Setting (ed) monitoring:
- POC glucose q1h (ADA 2026 §16)
- BMP + AG q2–4h (ADA 2026 §16)
- BHB q2–4h (JBDS 2023)
- VBG q2–4h until pH >7.30 (ADA 2026 §16)
- Continuous ECG until K normal (ADA 2026 §16)

Follow-up plan: 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
- Close-out criterion: discharge insulin regimen documented per ADA 2026 §16; education delivered; follow-up scheduled

Monitoring phase: 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)

Disposition

Current setting: ed — Confirm DKA per ADA 2026 §16, classify severity, initiate 5-pillar resuscitation, decide ward vs step-down vs ICU before transfer

Disposition criteria:
- Mild DKA + tolerating PO + reliable f/u → ward with SC protocol (ADA 2026 §16)
- Moderate DKA → step-down with IV insulin (ADA 2026 §16)
- Severe DKA / mixed DKA-HHS / pregnancy / peds / cerebral edema → ICU (ADA 2026 §16)

Escalation triggers (move to higher acuity):
- pH <7.0 / bicarb <5 → ICU (ADA 2026 §16)
- AMS / GCS <14 → ICU; peds suspect cerebral edema (ISPAD 2022)
- Refractory hypotension despite 30 mL/kg → ICU + sepsis workup (ADA 2026 §16)
- Hyperkalemia with ECG changes → ICU + emergency K Rx (ADA 2026 §16)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Pediatric DKA with new headache, bradycardia, hypertension, AMS, or focal neuro signs (ISPAD 2022)
- [LIFE_THREATENING] DKA in pregnancy (any trimester; ADA 2026 §16)
- [SEVERE] Serum K <3.3 mEq/L on initial labs (ADA 2026 §16)

Citations

- 2024 ADA/EASD/JBDS/AACE/DTS Consensus on Hyperglycemic Crises + ADA Standards of Care 2026 + JBDS-IP 02 (2023 update) + ISPAD 2022 Clinical Practice Consensus + ADA 2020 (insulin bolus removal) [PMID:39052901](https://pubmed.ncbi.nlm.nih.gov/39052901/)
- Cited evidence (PMID 19564476) [PMID:19564476](https://pubmed.ncbi.nlm.nih.gov/19564476/)

Last reconciled with current guidelines: 2026-05-22.
References
  • 2024 ADA/EASD/JBDS/AACE/DTS Consensus on Hyperglycemic Crises + ADA Standards of Care 2026 + JBDS-IP 02 (2023 update) + ISPAD 2022 Clinical Practice Consensus + ADA 2020 (insulin bolus removal) — PMID:39052901
  • Cited evidence (PMID 19564476) — PMID:19564476