From the Guidelines
The workup for diabetic ketoacidosis (DKA) should include a comprehensive assessment of the patient's clinical status, laboratory values, and identification of precipitating factors, with a focus on serum glucose, serum ketones, arterial blood gas analysis, and electrolyte imbalance, as outlined in the most recent guidelines 1. The initial evaluation should begin with a thorough history and physical examination, focusing on symptoms like polyuria, polydipsia, abdominal pain, nausea, vomiting, and altered mental status.
- Vital signs should be monitored closely, particularly for signs of dehydration and Kussmaul respirations.
- Laboratory evaluation must include:
- Serum glucose (typically >250 mg/dL)
- Serum ketones, with point-of-care testing for beta-hydroxybutyrate providing a more accurate assessment of ketosis than urine ketones 1
- Arterial blood gas analysis showing metabolic acidosis (pH <7.3, bicarbonate <18 mEq/L)
- Anion gap calculation (usually elevated >12 mEq/L)
- Complete blood count
- Comprehensive metabolic panel
- Urinalysis for glucose and ketones
- Serum osmolality Additional tests should include electrocardiogram, chest X-ray if respiratory symptoms are present, and cultures if infection is suspected.
- The workup should also identify potential precipitating factors such as infection, medication non-compliance, myocardial infarction, stroke, trauma, or new-onset diabetes. Management goals include restoration of circulatory volume and tissue perfusion, resolution of hyperglycemia, and correction of electrolyte imbalance and acidosis, with individualization of treatment based on a careful clinical and laboratory assessment 1. This comprehensive approach ensures appropriate diagnosis and guides management of DKA, which typically involves fluid resuscitation, insulin therapy, electrolyte replacement, and treatment of underlying causes, with continuous intravenous insulin being the standard of care in critically ill and mentally obtunded individuals 1.
From the Research
Workup for Diabetic Ketoacidosis (DKA)
- The diagnosis of DKA is characterized by a serum glucose level greater than 250 mg per dL, a pH less than 7.3, a serum bicarbonate level less than 18 mEq per L, an elevated serum ketone level, and dehydration 2.
- Common symptoms include polyuria with polydipsia, weight loss, fatigue, dyspnea, vomiting, preceding febrile illness, abdominal pain, and polyphagia 2.
- Measurement of A1C, blood urea nitrogen, creatinine, serum glucose, electrolytes, pH, and serum ketones; complete blood count; urinalysis; electrocardiography; and calculation of anion gap and osmolar gap can differentiate DKA from hyperosmolar hyperglycemic state, gastroenteritis, starvation ketosis, and other metabolic syndromes 2.
Laboratory Tests
- Serum glucose level: greater than 250 mg per dL 2
- pH: less than 7.3 2
- Serum bicarbonate level: less than 18 mEq per L 2
- Serum ketone level: elevated 2
- Electrolytes: including sodium, potassium, and chloride 2, 3
- Blood urea nitrogen and creatinine: to assess renal function 2
- Complete blood count: to assess for infection or other complications 2
- Urinalysis: to assess for ketones, glucose, and infection 2
- Electrocardiography: to assess for cardiac complications 2
Precipitating Causes
- Infection: the most common precipitating cause of DKA 4, 2, 5
- Insulin deficiency: the main precipitating factor 2
- Stress hormone excess: can lead to metabolic decompensation 4
- Dehydration: can exacerbate DKA 4, 6
- Fasting: can lead to metabolic decompensation 4
- New diagnosis of diabetes: a common precipitating cause of DKA 5
- Nonadherence to insulin therapy: a common precipitating cause of DKA 5