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GCC Nursing Guide — DKA & HHS Management
Endocrinology Critical Care JBDS / GCC Protocol Updated Apr 2026
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DKA Diagnostic Triad (ALL THREE required): Hyperglycaemia >11 mmol/L + Ketonaemia >3 mmol/L (or 2+ urine ketones) + Acidosis pH <7.3 or bicarbonate <15 mmol/L

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DKA Severity Classification

SeverityMildModerateSevere
pH7.25–7.307.00–7.24<7.00
Bicarbonate15–18 mmol/L10–14 mmol/L<10 mmol/L
Anion gap>10>12>12
Mental statusAlertAlert/drowsyStupor/coma
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DKA vs HHS — Key Differences

ParameterDKAHHS
Glucose>11 mmol/L>30 mmol/L
pH<7.3Normal (≥7.3)
KetonesStrongly positiveAbsent/trace
OsmolalityVariable>320 mOsm/kg
Bicarbonate<15 mmol/LNormal/raised
OnsetHours (T1DM)Days–weeks (T2DM)
VTE riskModerateVery High

Precipitating Factors

Most Common
Infection (UTI/pneumonia) Missed/omitted insulin New onset T1DM

Infection accounts for up to 40% of DKA cases. Always investigate for source — urine culture, CXR, blood cultures if febrile.

Drug-Related
Corticosteroids SGLT2 inhibitors Antipsychotics Cocaine/alcohol

SGLT2 inhibitors (empagliflozin, dapagliflozin) cause Euglycaemic DKA — glucose may be normal or near-normal.

Other Triggers
Acute MI / stroke Surgery / trauma Pancreatitis Pregnancy

In GCC context: Ramadan fasting — missed insulin, altered meal timing, and dehydration significantly increase DKA risk in T1DM patients.

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EDKA — Euglycaemic DKA

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Critical awareness: EDKA presents with normal or near-normal glucose (typically 8–14 mmol/L) but positive ketones and acidosis — easily missed.

Primary causeSGLT2 inhibitor use
MechanismGlucosuria lowers glucose; ketogenesis continues
Other triggersFasting, low carb diet, alcohol, illness
ManagementSame DKA protocol; hold SGLT2i

Always ask about SGLT2 inhibitor use (gliflozins) in any patient with ketoacidosis — even if glucose appears normal.

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GCC Context — High-Risk Scenarios

Ramadan DKA Risk
  • T1DM patients may omit or adjust insulin during fasting hours
  • Dehydration in summer heat accelerates DKA onset
  • Rapid suhoor-to-iftar glucose swings destabilise control
  • Many patients fast despite medical advice — structured plan essential
Epidemiology
  • GCC has among the highest T1DM & T2DM prevalence globally
  • UAE, Saudi Arabia, Kuwait: T2DM prevalence 15–25%
  • Young T1DM patients frequently present in DKA at diagnosis
  • HHS more common in elderly T2DM patients with poor fluid intake
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JBDS Protocol Order: (1) IV fluids first → (2) Check K+ → (3) Start insulin only if K+ >3.5 → (4) Potassium replacement → (5) Monitor hourly

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IV Fluid Resuscitation — 0.9% NaCl

  1. 1L 0.9% NaCl over 1 hour — immediate resuscitation
  2. 500 mL/hr × 2 hours (next 2 bags)
  3. 250 mL/hr × 4 hours — reassess fluid balance
  4. 125 mL/hr × 4 hours — continue monitoring
  5. When glucose <14 mmol/L: switch to 10% dextrose at 125 mL/hr alongside 0.9% NaCl
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Target glucose during DKA: 10–14 mmol/L. Do NOT aim for euglycaemia — too rapid correction risks cerebral oedema.

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Fixed Rate Insulin Infusion (FRIII)

Standard FRIII Dose

0.1 units/kg/hr of soluble insulin

  • Do NOT use a sliding scale — fixed weight-based rate is essential
  • Continue subcutaneous long-acting insulin (e.g. glargine) during FRIII
  • Maximum rate: usually no cap, but reassess if no response by 2h
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NEVER start insulin if K+ <3.5 mmol/L. Replace potassium first. Insulin drives K+ intracellularly and can cause fatal arrhythmias.

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Potassium Replacement Protocol

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Hypokalaemia is the most common cause of death in DKA treatment. Insulin + rehydration both shift K+ intracellularly — mandatory monitoring and replacement.

Serum K+ level Potassium in IV bag Insulin action Notes
<3.5 mmol/L 40 mmol/L — URGENT replacement STOP INSULIN — call senior Give KCl via central/large vein; ECG monitoring; repeat K+ in 1h
3.5–5.5 mmol/L 40 mmol/L in each litre Continue FRIII Target K+ 4.0–5.0 mmol/L during DKA treatment
>5.5 mmol/L No potassium in bag Continue FRIII Recheck K+ in 2h; do not add potassium until <5.5

DKA Resolution Criteria

ALL of the following must be met before stopping IV insulin:

pH>7.3
Blood ketones<0.6 mmol/L
Blood glucose<14 mmol/L
Bicarbonate>15 mmol/L
Patient eating/drinkingYes — tolerating oral intake
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2-hour overlap rule: Give subcutaneous insulin dose and wait 2 hours BEFORE stopping IV insulin infusion.

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Bicarbonate & Phosphate

Bicarbonate — Controversial
  • Only consider if pH <6.9 (severe acidosis)
  • Requires senior/consultant decision — not routine
  • Risks: paradoxical CNS acidosis, hypokalaemia worsening, alkalosis overshoot
  • If used: 100 mmol NaHCO₃ over 60 min with 10 mmol KCl
Phosphate
  • Routine phosphate replacement NOT recommended in DKA
  • Check phosphate if prolonged DKA, weakness, or haemolysis suspected
  • Severe hypophosphataemia (<0.32 mmol/L): consider replacement
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HHS key principle: Slower is safer. Avoid rapid fluid or osmolality correction. Target osmolality reduction of 3–8 mOsm/kg/hr only.

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HHS Diagnostic Criteria

Glucose

>30 mmol/L

Typically much higher than DKA. Extreme hyperglycaemia drives hyperosmolality.

Osmolality

>320 mOsm/kg

Formula: 2(Na) + glucose + urea (all in mmol/L). Often 350–400+ in HHS.

Ketones

Absent / Trace

No significant ketonaemia. pH normal (>7.3). This distinguishes HHS from DKA.

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HHS Fluid Replacement

Target: replace fluid deficit over 24–48 hours — NOT rapidly.

  1. Start with 0.9% NaCl — even though hyperosmolar, this is less hypotonic than plasma initially
  2. Typical rate: 3–5 L over first 12 hours (guided by clinical state)
  3. If osmolality not falling adequately: switch to 0.45% (half-normal) saline
  4. Monitor osmolality every 2 hours — target fall of 3–8 mOsm/kg/hr
  5. When glucose <14 mmol/L: switch to 5% dextrose to maintain glucose 10–15 mmol/L
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Insulin in HHS

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Do NOT start insulin immediately in HHS. Fluids alone will lower glucose. Premature insulin risks hypoglycaemia and rapid osmolality shift.

Start insulin whenGlucose stops falling with fluids alone
OR whenKetonaemia develops (mixed DKA/HHS)
Insulin rate in HHS0.05 units/kg/hr (lower than DKA)
Glucose target10–15 mmol/L
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Thromboprophylaxis — Mandatory in HHS

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HHS carries very high VTE risk due to extreme hyperviscosity, dehydration, and immobility. DVT/PE is a major cause of HHS mortality.

LMWH (enoxaparin)Start immediately unless contraindicated
TED stockingsApply if no peripheral vascular disease
DurationContinue until fully mobile
Electrolyte Monitoring — q2–4 hours
  • Sodium: may rise as glucose falls (corrected Na formula)
  • Potassium: same replacement protocol as DKA
  • Phosphate: monitor in prolonged HHS
  • Magnesium: check if arrhythmias or weakness present
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Cerebral Oedema Risk

Cerebral oedema is more common in children with DKA but can occur in HHS with rapid osmolality correction. The brain adapts to hyperosmolality — rapid correction causes osmotic water movement into brain cells.

Warning signsHeadache, confusion worsening after initial improvement
Also watch forBradycardia, rising BP, visual changes
Management of Suspected Cerebral Oedema
  1. Stop IV fluids — slow or pause infusion immediately
  2. Call senior/intensivist urgently
  3. Give mannitol 0.5–1 g/kg IV over 20 min
  4. Or hypertonic 3% NaCl as alternative
  5. Consider CT head to exclude other causes
  6. ICU transfer — may need intubation
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Hourly Monitoring Chart — DKA/HHS

ParameterFrequencyTarget / Action
Blood glucose (CBG)HourlyDKA: 10–14 mmol/L; add dextrose if <14 mmol/L
Blood ketonesHourlyTarget fall ≥0.5 mmol/L/hr; resolution <0.6
Serum potassium2-hourly (1h if <3.5)Target 4.0–5.0 mmol/L; adjust replacement accordingly
Venous blood gas (pH/HCO₃)2-hourlyTarget pH >7.3; bicarbonate rising
Urine outputHourlyTarget ≥0.5 mL/kg/hr — catheterise if oliguric
Fluid balanceHourlyDocument all inputs/outputs; cumulative total q4h
Vital signs (HR, BP, SpO₂, RR, Temp)HourlyNEWS2 scoring; escalate if deteriorating
GCS / neurological statusHourlyDeteriorating GCS — consider cerebral oedema
Osmolality (HHS)2-hourlyTarget reduction 3–8 mOsm/kg/hr
U&E, Mg, Phosphate4-hourlyReplace electrolytes as per protocol
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Hypokalaemia — ECG Changes

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Continuous ECG monitoring mandatory if K+ <3.0 mmol/L or patient has cardiac history.

Flattening / inversion of T-wavesEarly sign
U-waves (after T-wave)Characteristic finding
Prolonged QT intervalArrhythmia risk
ST depressionMore severe hypokalaemia
Ventricular tachycardia/fibrillationK+ <2.5 risk
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Hypoglycaemia During DKA Treatment

Glucose can fall rapidly with IV insulin. Do NOT stop insulin — switch fluid to prevent hypoglycaemia while maintaining insulinaemia to clear ketones.

Glucose <14 mmol/LAdd 10% dextrose 125 mL/hr alongside saline
Glucose <6 mmol/LReduce FRIII to 0.05 units/kg/hr
Symptomatic hypoglycaemiaIV 10% glucose bolus; review insulin rate
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Never stop insulin to treat hypoglycaemia in DKA — give dextrose instead. Stopping insulin allows ketogenesis to continue.

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Aspiration Risk

Indication for NG tubeGCS <12 or persistent vomiting
PurposeGastric decompression; reduce aspiration risk
Positioning30–45° head-up if tolerated

DKA causes gastroparesis — gastric stasis increases vomiting risk even if patient appears alert. Consider NG early if vomiting uncontrolled.

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Transition: IV to SC Insulin

Premature transition to subcutaneous insulin leads to rebound ketoacidosis. Strict criteria must be met.

Must be eating and drinkingTolerating meals
DKA resolution criteria metpH >7.3, ketones <0.6
2-hour overlapGive SC dose, wait 2h then stop FRIII
Timing of SC doseGive with a meal, not fasting

In patients without known insulin regimen — use T1DM starter regimen or endocrinology review before discharge.

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Root Cause Identification — Prevent Recurrence

Investigate why DKA occurred
  • Missed insulin: intentional or accidental?
  • Insulin pen/pump failure (check device)
  • Incorrect injection technique or sites
  • Insulin storage problems (heat in GCC climate)
  • Financial barriers to insulin access
Infection screen
  • Urine MC&S (commonest source — UTI)
  • Chest X-ray (pneumonia)
  • Blood cultures if pyrexial (>38°C)
  • Wound swabs if diabetic foot present
  • COVID-19/influenza rapid test
Psychosocial factors
  • Mental health — depression, eating disorders (omitted insulin for weight loss)
  • Diabetes burnout — explore with non-judgmental approach
  • Social support — living alone, language barriers
  • Referral to diabetes specialist nurse before discharge
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Sick Day Rules — DRASTIC

D — Drink fluids

Extra sugar-free fluids (water, diluted juice). If vomiting, sip small amounts frequently. Aim 3L/day minimum.

R — Rest & recover

Reduce activity. Stress hormones (cortisol, adrenaline) raise blood glucose further.

A — Act on high glucose

Check blood glucose every 2–4 hours when unwell. If consistently >14 mmol/L, check ketones.

S — Seek ketones

Check blood ketones every 2–4 hours if glucose >14 mmol/L. Blood meter preferred over urine strips.

T — Take insulin — NEVER STOP

Even if not eating, continue long-acting insulin. Short-acting may need increasing by 10–20% during illness. Call diabetes team if unsure.

I — Identify cause of illness

Treat underlying infection. Antibiotics if confirmed bacterial source. Paracetamol for fever — avoid NSAIDs if dehydrated.

C — Call for help if:
  • Vomiting and unable to keep fluids down
  • Blood ketones >3.0 mmol/L
  • Glucose >25 mmol/L and rising
  • Confusion, drowsiness, or not responding normally
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Ketone Testing at Home

Preferred methodBlood ketone meter (beta-hydroxybutyrate)
AlternativeUrine ketone strips (less accurate, delayed)
When to testGlucose >14 mmol/L, feeling unwell, vomiting
Ketones <1.0 mmol/LLow risk — continue monitoring
Ketones 1.0–3.0 mmol/LModerate risk — extra insulin, fluids, recheck 1h
Ketones >3.0 mmol/LEmergency — go to hospital now

Insulin Pump & DKA Risk

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Pump users are at higher DKA risk. No subcutaneous long-acting insulin — pump failure means total insulin deficiency within 4–8 hours.

Time to DKA without basal4–8 hours
Common causesCannula blockage, tubing kink, battery failure
Action if pump failsSwitch to SC injection pen immediately
Cannula change frequencyEvery 2–3 days maximum

All pump users should have a backup pen and long-acting insulin prescription. Education on recognising pump failure symptoms is essential.

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Ramadan Fasting — T1DM Protocol

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T1DM fasting during Ramadan carries high DKA risk. Structured pre-Ramadan education and individualised insulin adjustment plan is mandatory. Many Islamic scholars advise T1DM patients are exempt from fasting.

Insulin Adjustments
  • Pre-dawn (Suhoor): reduce long-acting by 15–20%
  • Iftar: rapid-acting with meal as usual
  • Mid-fast boluses should be avoided
  • Continuous glucose monitoring (CGM) strongly recommended
Monitoring During Fast
  • Break fast if glucose <4.0 mmol/L
  • Break fast if glucose >16.7 mmol/L
  • Check glucose at pre-dawn, midday, pre-Iftar, 2h post-Iftar
  • Check ketones if unwell or glucose >14 mmol/L
Break the Fast If:
  • Symptomatic hypoglycaemia
  • Glucose <3.9 mmol/L at any point
  • Vomiting or illness during fast
  • Ketones >1.0 mmol/L
  • Blood glucose >16.7 mmol/L
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Post-DKA Re-education Checklist

Before Discharge — Cover:
  • Why DKA occurred — address the root cause
  • Injection technique assessment (lipohypertrophy?)
  • Insulin storage (avoid heat >25°C — critical in GCC summer)
  • Sick day rules — written Arabic/English copy given
  • Ketone meter training and strips supplied
  • Emergency contact numbers: diabetes nurse, out-of-hours
Follow-up Referrals:
  • Diabetes specialist nurse within 1 week
  • Dietitian — carbohydrate counting review
  • Endocrinologist if recurrent DKA (>1/year)
  • Psychology/psychiatry if deliberate omission suspected
  • Social worker if financial barriers to insulin identified
  • Ophthalmology/nephrology if long-standing poor control
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DKA Diagnostic Criteria — Exam Table

CriterionValue
Blood glucose>11 mmol/L (200 mg/dL)
Blood ketones>3.0 mmol/L
Urine ketones (alternative)2+ or more
pH<7.3
Bicarbonate<15 mmol/L
Anion gap>10 (corrected)
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High-Yield Exam Q&A

Potassium (K+). Insulin drives K+ into cells, causing dangerous hypokalaemia. The biggest DKA killer.

DHA/DOH/SCFHS commonly test the K+ protocol. Never start insulin if K+ <3.5 mmol/L.

0.1 units/kg/hr of soluble insulin as a fixed rate infusion — not a sliding scale.

SGLT2 inhibitors (gliflozins — empagliflozin, dapagliflozin, canagliflozin). Glucose may appear normal but ketones are elevated.

Fluids alone will lower glucose in HHS. Premature insulin risks hypoglycaemia and rapid osmolality shift causing cerebral oedema.

When transitioning from IV to SC insulin in DKA resolution: give the subcutaneous dose and continue IV insulin for 2 more hours before stopping the infusion.

LMWH thromboprophylaxis (e.g. enoxaparin) must be started immediately in HHS unless contraindicated. HHS has very high hyperviscosity and VTE mortality.

pH >7.3 AND blood ketones <0.6 mmol/L AND glucose <14 mmol/L AND patient eating and drinking.

DKA Severity & Potassium Protocol Calculator

7.15 6.80 — 7.40
    Resolution Criteria Status
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    JBDS Protocol — Key Steps Summary

    Hour 0–1: Initial Actions
    1. IV access × 2, bloods: VBG, U&E, glucose, ketones, FBC, CRP, cultures
    2. 1L 0.9% NaCl over 1 hour
    3. Check K+ result BEFORE starting insulin
    4. Urinary catheter if oliguric or obtunded
    5. 12-lead ECG (hyperkalaemia / hypokalaemia)
    Hour 1–6: Active Treatment
    1. FRIII at 0.1 units/kg/hr (if K+ >3.5)
    2. Potassium in bags per protocol
    3. Continue IV fluids (500 mL/hr × 2 bags)
    4. Hourly glucose & ketone monitoring
    5. Add dextrose when glucose <14 mmol/L
    Resolution: Transition Plan
    1. Confirm ALL resolution criteria met
    2. Patient eating and tolerating food
    3. Calculate SC insulin regimen
    4. Give SC dose — wait 2h — stop FRIII
    5. Diabetes specialist nurse review before discharge