DKA/HONK Management

-3 components: Diabetes (BG >250), Ketones (serum/urine BHB*, acetone, acetoacetate), Acidosis (pH<7.3, bicarb <18)
(1) Fluid resuscitate: 15-20 cc/kg NS bolus within first hour
(2) Supplement K if <4 (No benefit for supplementing phosphate)
(3) Give insulin regular/Humalog 0.1 U/kg gtt

Continue until Anion Gap closes. Repeat blood gases q1h.

If glucose drops <150, start D5 0.45NS alongside insulin.

Evaluate for precipitants.

-Note: it is possible for the anion gap to be low/closed at diagnosis/???
-Note: if acidosis is worsening, look for concomitant hyperchloremic metabolic acidosis

*BHB is most sensitive. (BHB comprises ~78%. Acetoacetate ~20%, but is unstable and breaks down into CO2 and acetone, which comprises the remaining 2%.)


Euglycemic DKA =  metabolic derangement (low insulin / high glucagon) causing excess ketone production without hyperglycemia
– vomiting is most common symptom
– look for elevated AG and acidosis without high BGM – send urine and serum ketones!
– still require iv hydration and lyte replacement
– require iv insulin to close the gap – however will need to start D5-containing fluids concomitantly
– associated with sodium-glucose co-transporter 2 inhibitors (SGLT-2 inhibitors, or the “zins”)


-Glucose usually very high (600-1000), no/minimal ketones, pH>7.3
-HONK is managed the same way, except the fluid deficit is much greater (the dehydration is chronic). No established guidelines.

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