Main changes in treatment recommendations between 2009 consensus statement and 2024 consensus report
| 2009 Consensus statement4 | 2024 Consensus report5 | ||
|---|---|---|---|
| Fluids | Type | Isotonic saline (0.9% NaCl) during the first hour Subsequently, use 0.45% NaCl if serum sodium is high or normal; continue 0.9% NaCl if serum sodium is low Change to dextrose 5% with 0.45% NaCl when glucose reaches 200 mg/dL in DKA and 300 mg/dL in HHS | Isotonic saline or balanced crystalloid solutions, with subsequent choice of fluids depending on fluid balance, hemodynamics, and sodium concentration 0.45% NaCl is indicated only if osmolality is not declining in HHS despite adequate fluid and insulin therapy Add dextrose 5% or 10% when glucose reaches < 250 mg/dL for both DKA and HHS |
| Volume | 15–20 mL/kg/hour or 1–1.5 L in the first hour Subsequently, 250–500 mL/hour | 500–1,000 mL/hour during the first 2–4 hours Subsequently, adjust rate as clinically appropriate | |
| Time to correction of estimated fluid deficit | 24 hours | 24–48 hours (replace 50% of fluid deficit in the first 8–12 hours) | |
| Insulin | Initial | Both DKA and HHS: 0.1 units/kg in IV bolus, followed by FRIII at 0.1 units/kg/hour OR FRIII at 0.14 units/kg/hour | Moderate and severe DKA: FRIII at 0.1 units/kg/hour (consider 0.1 units/kg IV bolus if IV access is delayed) OR Nurse-driven insulin infusion protocol Mild and moderate DKA: Subcutaneous rapid-acting insulin analogue 0.1 units/kg every 1 hour or 0.2 units/kg every 2 hours HHS: FRIII at 0.05 units/kg/hour Mixed DKA/HHS: treat as DKA |
| Initial glucose goal for dextrose initiation | DKA: < 200 mg/dL HHS: < 300 mg/dL | DKA and HHS: < 250 mg/dL | |
| Maintenance after dextrose initiation | Decrease infusion to 0.02–0.05 units/kg/hour until resolution | Decrease infusion to 0.05 units/kg/hour until resolution | |
| Glucose goal until resolution | DKA: 150–200 mg/dL HHS: 200–300 mg/dL | DKA: 150–200 mg/dL HHS: 200–250 mg/dL | |
| Potassium | Low | < 3.3 mmol/L: give 20–30 mmol/hour and postpone insulin therapy until serum potassium > 3.3 mmol/L | < 3.5 mmol/L: give 10–20 mmol/hour and postpone insulin therapy until serum potassium > 3.5 mmol/L |
| Normal | 3.3–5.2 mmol/L: give 20–30 mmol in each liter of IV fluid to maintain serum potassium of 4–5 mmol/L | 3.5–5.0 mmol/L: give 10–20 mmol in each liter of IV fluid to maintain serum potassium of 4–5 mmol/L | |
| High | > 5.2 mmol/L: do not give potassium but check serum potassium every 2 hours | > 5.0 mmol/L: do not give potassium but check serum potassium every 2 hours |
DKA = diabetic ketoacidosis; FRIII = fixed-rate intravenous insulin infusion; HHS = hyperglycemic hyperosmolar state; IV = intravenous