𧬠DKA Assessment Aid
Diabetic ketoacidosis criteria and severity. Emergency: call 911.
EDUCATIONAL ONLY. Suspected DKA is a medical emergency: seek emergency care immediately.
Diabetic ketoacidosis is a medical emergency: without enough insulin, the body burns fat into ketoacids, the blood turns acidic, and dehydration spirals. The ADA diagnostic criteria combine glucose, pH, bicarbonate, anion gap, and ketones, and severity bands guide ICU vs floor care. This page checks the criteria from lab values and explains each piece. If DKA is suspected, do not calculate, go to the emergency department.
How to Use This Assessment Aid
Enter the lab values. The criteria check, anion gap, corrected sodium, and severity appear.
Enter glucose, pH, sodium, chloride, bicarbonate, and ketone status.
Read whether ADA criteria are met and the severity band.
If criteria are met, seek emergency care immediately. This page educates; the ED treats.
The ADA Criteria and Severity Bands
Each criterion reflects the pathophysiology: hyperglycemia from insulin deficiency, acidemia from ketoacids consuming bicarbonate, the anion gap from unmeasured ketoacid anions, ketones as the direct evidence. The anion gap is the key discriminator: DKA is a high-anion-gap metabolic acidosis, and the gap quantifies the ketoacid load. Corrected sodium matters because hyperglycemia dilutes sodium; the uncorrected number misleads fluid decisions. Effective osmolality over 320 suggests hyperosmolar overlap, changing management.
Euglycemic DKA is the exception that proves the rule: with SGLT2 inhibitors, pregnancy, or starvation, DKA can occur with glucose under 250. The criteria bend but the physiology does not: acidemia, ketonemia, and anion gap still diagnose. If the clinical picture screams DKA with a modest glucose, check ketones and gases anyway.
Worked Example
Glucose 450, pH 7.22, Na 135, Cl 100, HCO3 12, ketones positive. Anion gap = 135 - (100+12) = 23: markedly high. Corrected Na = 135 + 1.6 x 3.5 = 140.6. Effective osmolality = 2 x 140.6 + 25 = 306. Criteria: glucose >250 yes, pH <7.30 yes, bicarb <18 yes, AG >10 yes, ketones yes: DKA present, moderate severity (pH 7.22). Management pattern: isotonic fluids, insulin infusion (after potassium checked), aggressive potassium repletion, and hunting the trigger: infection, missed insulin, new diagnosis, MI, pancreatitis. The trigger search matters as much as the protocol.
Treatment Principles
Fluids first: isotonic saline or balanced crystalloids restore perfusion, typically liters in the first hours. Insulin second: an infusion (0.1 units/kg/hr after a bolus in some protocols) stops ketogenesis; it starts only after potassium is known, because insulin drives potassium into cells and hypokalemia kills. Potassium third: replete aggressively, holding insulin if K is under 3.3. Bicarbonate is reserved for pH under 6.9. Glucose gets added to fluids when it falls to ~200-250 so insulin can continue clearing ketones without hypoglycemia. Resolution criteria: glucose under 200, bicarb over 18, anion gap closed, pH over 7.3, then transition to subcutaneous insulin with overlap.
Cerebral edema is the feared complication, mostly in children: headache, altered mental status during treatment needs immediate action. Adults face hypokalemia, hypoglycemia, and fluid overload as the main iatrogenic risks. Protocols exist because the sequence matters: fluids before insulin, potassium before or with insulin, glucose added later, overlap at transition. This page shows the criteria; the protocol belongs to the treating team.
Prevention: Sick-Day Rules
Most DKA is preventable. Sick-day rules for type 1 diabetes: never stop basal insulin when ill, check glucose and ketones every few hours during illness, stay hydrated, and seek care for persistent vomiting, moderate-large ketones, or inability to keep fluids down. Missed insulin doses and pump failures are the commonest triggers; infection is the commonest medical trigger. Every person with type 1 diabetes should have a written sick-day plan and ketone strips at home. DKA at diagnosis, especially in children, is often the first sign of type 1 diabetes: new excessive thirst, urination, and weight loss deserve prompt testing, not waiting.
Related Calculators
Keep exploring: try our macro calculator and calorie needs (TDEE) for the next piece of the picture.
For informational purposes only, not medical advice. Consult a healthcare professional.
Frequently Asked Questions
What are the diagnostic criteria for DKA?
Per ADA: glucose >250 mg/dL, arterial pH <7.30, bicarbonate <18 mEq/L, anion gap >10, and ketonemia/ketonuria. All five together define classic DKA. Euglycemic DKA (often with SGLT2 inhibitors) can occur with glucose under 250.
How is DKA severity classified?
By pH (and bicarbonate): mild pH 7.25-7.30 (bicarb 15-18), moderate pH 7.00-7.24 (bicarb 10-15), severe pH <7.00 (bicarb <10). Severity guides ICU vs floor care and monitoring intensity.
What is the anion gap in DKA?
Na - (Cl + HCO3), typically markedly high (>20s) from ketoacid anions. The gap quantifies the ketoacid load and its closure marks resolution. Normal is roughly 8-12 mEq/L.
Why correct sodium in DKA?
Hyperglycemia draws water from cells, diluting serum sodium. Corrected Na = measured + 1.6 x ((glucose-100)/100). The corrected value guides fluid therapy; the uncorrected number misleads.
What triggers DKA?
Missed insulin doses, pump failure, infection, new-onset type 1 diabetes, MI, pancreatitis, steroids, and SGLT2 inhibitors (euglycemic DKA). Finding and treating the trigger is as important as the DKA protocol itself.
How is DKA treated?
Isotonic fluids, insulin infusion (after checking potassium), aggressive potassium repletion, and trigger treatment. Bicarbonate only if pH <6.9. Transition to subcutaneous insulin with overlap once resolved (glucose <200, gap closed, bicarb >18).
What is euglycemic DKA?
DKA with glucose under 250 mg/dL, seen with SGLT2 inhibitors, pregnancy, starvation, or alcohol use. The acidosis, ketones, and anion gap still diagnose it. Do not let a modest glucose rule out DKA clinically.
What are sick-day rules for type 1 diabetes?
Never stop basal insulin when ill; check glucose and ketones frequently; stay hydrated; seek care for vomiting, moderate-large ketones, or inability to keep fluids down. A written plan and home ketone strips prevent most episodes.
What is the difference between DKA and HHS?
DKA: ketoacidosis with moderate hyperglycemia, in type 1 (and some type 2). HHS: extreme hyperglycemia (>600) with hyperosmolality and minimal ketosis, in type 2. Overlap occurs. Both are emergencies with different fluid and insulin emphases.
Can DKA be fatal?
Yes, though mortality is under 1% with prompt treatment in adults. Delays, missed triggers, cerebral edema (mainly children), and severe hypokalemia cause the deaths. Suspected DKA needs emergency care immediately.