Summary

2024 ADA/EASD/JBDS/AACE/DTS consensus update on diagnosis and management of DKA and HHS in adults, revising the 2009 ADA statement. Key changes: lowered DKA glucose threshold to ≥200 mg/dL (or any prior diabetes history) to capture euglycemic DKA, adoption of β-hydroxybutyrate ≥3.0 mmol/L as the preferred ketone criterion, endorsement of balanced crystalloids as an alternative to 0.9% saline, and expanded guidance on SGLT2 inhibitor–associated DKA, pregnancy, ESKD, and frail older adults.

Key Recommendations

Diagnose DKA by all three criteria: glucose ≥200 mg/dL (or known diabetes) + β-hydroxybutyrate ≥3.0 mmol/L (or urine ketones ≥2+) + pH <7.3 or bicarbonate <18 mmol/L.
Diagnose HHS by glucose ≥600 mg/dL, effective osmolality >300 mOsm/kg (or total >320), β-hydroxybutyrate <3.0 mmol/L, and pH ≥7.3 with bicarbonate ≥15 mmol/L.
Use β-hydroxybutyrate (venous or capillary POCT) rather than urine ketones for diagnosis and monitoring response.
Initiate fluid resuscitation with 0.9% saline or balanced crystalloid (Ringer’s lactate, Plasmalyte) at 500–1,000 mL/h for 2–4 h; balanced crystalloids may speed DKA resolution and reduce hyperchloremic acidosis.
Start fixed-rate IV insulin infusion at 0.1 units/kg/h for moderate/severe DKA; for HHS without significant ketosis start 0.05 units/kg/h.
Add 5–10% dextrose to IV fluids once glucose falls below 250 mg/dL in DKA (or at outset in euglycemic DKA) and continue insulin until ketoacidosis resolves.
Replace potassium: hold insulin if K+ <3.5 mmol/L and replace 10–20 mmol/h; add 10–20 mmol/L K+ to fluids when K+ is 3.5–5.0 mmol/L.
Do not give routine bicarbonate; consider only if pH <7.0 (100 mmol in 400 mL sterile water every 2 h until pH >7.0).
For mild DKA, subcutaneous rapid-acting insulin analog protocols are an acceptable alternative to IV infusion and can be managed outside the ICU.
Stop SGLT2 inhibitors on admission; do not initiate/continue SGLT2 inhibitors during hospitalization, and avoid in T1D.
Overlap subcutaneous basal insulin with IV insulin for 1–2 h before discontinuing the drip; estimate TDD at 0.5–0.6 units/kg/day (0.3 units/kg/day if frail/CKD/elderly).
Use prophylactic-dose LMWH for VTE prevention and monitor for hypoglycemia, hypokalemia, cerebral edema, AKI, and osmotic demyelination during treatment.

Thresholds & Doses

DKA glucose criterion: ≥200 mg/dL (11.1 mmol/L) or any prior diabetes history (lowered from >250 mg/dL).
DKA ketone criterion: β-hydroxybutyrate ≥3.0 mmol/L or urine ketones ≥2+.
DKA acidosis criterion: pH <7.3 and/or bicarbonate <18 mmol/L.
HHS criteria: glucose ≥600 mg/dL (33.3 mmol/L); effective osmolality >300 mOsm/kg or total >320 mOsm/kg; β-OHB <3.0 mmol/L; pH ≥7.3 and bicarbonate ≥15 mmol/L.
DKA severity — mild: pH 7.25–7.30 or HCO3 15–18, β-OHB 3.0–6.0; moderate: pH 7.0–7.25 or HCO3 10–<15; severe: pH <7.0, HCO3 <10, or β-OHB >6.0.
Euglycemic DKA: glucose <200 mg/dL (11.1 mmol/L) with ketosis and acidosis.
Initial fluids: 0.9% saline or balanced crystalloid 500–1,000 mL/h for first 2–4 h; replace deficit over 24–48 h.
IV insulin infusion: 0.1 units/kg/h fixed rate for DKA; 0.05 units/kg/h for HHS without significant ketosis; optional 0.1 units/kg bolus if delayed IV access.
Add dextrose (5–10%) when glucose <250 mg/dL (13.9 mmol/L); reduce insulin to 0.05 units/kg/h.
Target glucose during therapy: 150–200 mg/dL in DKA; 200–250 mg/dL in HHS until resolution.
Potassium: hold insulin and give 10–20 mmol/h K+ if K+ <3.5 mmol/L; add 10–20 mmol/L K+ to each liter of fluid if K+ 3.5–5.0 mmol/L; no K+ if K+ >5.0.
Bicarbonate indication: pH <7.0 only — 100 mmol NaHCO3 (8.4%) in 400 mL sterile water every 2 h until pH >7.0.
Resolution criteria — DKA: venous pH >7.3 or bicarbonate >18 mmol/L and ketones <0.6 mmol/L; HHS: osmolality <300 mOsm/kg, urine output >0.5 mL/kg/h, glucose <250 mg/dL.
Osmolality should fall by 3.0–8.0 mOsm/kg/h to avoid osmotic demyelination.
Transition basal insulin TDD: 0.5–0.6 units/kg/day (0.3 units/kg/day for frail/CKD); overlap SC insulin 1–2 h with IV insulin.
Hypoglycemia threshold: <70 mg/dL (3.9 mmol/L); severe <40 mg/dL (2.2 mmol/L) associated with 4.8-fold higher mortality.
Follow-up within 2–4 weeks after discharge to prevent recurrent DKA.

Citations

Figure 2 (Diagnostic Criteria) — DKA and HHS diagnostic thresholds
Table 2 (DKA classification) — severity grading and level of care
Figure 4 (Treatment Pathways) — fluids, insulin, and potassium algorithms
Figure 5 (Transition to Maintenance Insulin) — TDD estimation and basal-bolus initiation
Section 4 (Recommended Treatment) — balanced crystalloid vs saline, insulin dosing, bicarbonate indication
Table 3 (Complications) — hypoglycemia, hypokalemia, cerebral edema, osmotic demyelination, AKI
Table 4 (Special Populations) — SGLT2 inhibitors, ESKD, pregnancy, frail elderly, COVID-19
Section 7 (Prevention) — discharge planning, follow-up timing, SDOH screening