From the Guidelines
Diabetic ketoacidosis (DKA) is diagnosed when a patient meets three key clinical criteria: hyperglycemia, ketosis, and metabolic acidosis, with the most recent and highest quality study suggesting criteria of blood glucose >250 mg/dl, pH <7.3, and bicarbonate <18 mEq/l 1.
Clinical Criteria for DKA
The clinical criteria for DKA include:
- Hyperglycemia: blood glucose level greater than 250 mg/dL
- Ketosis: presence of ketones in blood or urine
- Metabolic acidosis: pH less than 7.3 and bicarbonate less than 18 mEq/L Additionally, patients typically present with an anion gap greater than 10-12 mEq/L.
Laboratory Evaluation
Laboratory evaluation should include:
- Comprehensive metabolic panel
- Complete blood count
- Urinalysis
- Serum ketones (beta-hydroxybutyrate)
- Arterial or venous blood gas
- Assessment of precipitating factors such as infection
Pathophysiology
The pathophysiology of DKA involves insulin deficiency leading to increased lipolysis, fatty acid oxidation, and ketone body production, while hyperglycemia results from decreased glucose utilization and increased gluconeogenesis.
Treatment
Prompt recognition of these criteria is essential as DKA is a medical emergency requiring immediate treatment with insulin, fluid resuscitation, and electrolyte replacement, with the most recent study suggesting that there is no significant difference in outcomes for intravenous human regular insulin versus subcutaneous rapid-acting analogs when combined with aggressive fluid management for treating mild or moderate DKA 1.
From the FDA Drug Label
Hyperglycemia, diabetic ketoacidosis, or hyperosmolar coma may develop if the patient takes less Humulin R U-100 than needed to control blood glucose levels Early signs of diabetic ketoacidosis include glycosuria and ketonuria Polydipsia, polyuria, loss of appetite, fatigue, dry skin, abdominal pain, nausea and vomiting and compensatory tachypnea come on gradually, usually over a period of some hours or days, in conjunction with hyperglycemia and ketonemia. The first symptoms of DKA usually come on gradually, over a period of hours or days, and include a drowsy feeling, flushed face, thirst, loss of appetite, and fruity odor on the breath. With DKA, blood and urine tests show large amounts of glucose and ketones.
The clinical criteria for Diabetic Ketoacidosis (DKA) include:
- Hyperglycemia: high blood glucose levels
- Ketonuria: presence of ketones in the urine
- Glycosuria: presence of glucose in the urine
- Polydipsia: excessive thirst
- Polyuria: excessive urination
- Loss of appetite
- Fatigue
- Dry skin
- Abdominal pain
- Nausea and vomiting
- Compensatory tachypnea: rapid breathing
- Drowsy feeling
- Flushed face
- Fruity odor on the breath
- Large amounts of glucose and ketones in blood and urine tests 2 2 2
From the Research
Clinical Criteria for Diabetic Ketoacidosis (DKA)
The clinical criteria for DKA include:
- Serum glucose level greater than 250 mg per dL 3, 4, 5
- pH less than 7.3 3, 4, 5
- Serum bicarbonate level less than 18 mEq per L 3, 4, 5
- Elevated serum ketone level 3, 4, 5
- Dehydration 3, 4
Diagnostic Considerations
Other diagnostic considerations for DKA include:
- Measurement of A1C, blood urea nitrogen, creatinine, serum glucose, electrolytes, pH, and serum ketones 3, 4
- Complete blood count 3, 4
- Urinalysis 3, 4
- Electrocardiography 3, 4
- Calculation of anion gap and osmolar gap 3, 4
Severity of DKA
The severity of DKA can be classified based on the pH level, with severe cases having a pH ≤ 7.00 6 or ≤ 6.9 6. Very severe DKA in type 2 diabetes is not uncommon and can be managed following standard published or institutional guidelines 6.
Treatment and Management
Treatment for DKA involves:
- Administering intravenous fluids and insulin 3, 4, 5
- Monitoring glucose and electrolyte levels 3, 4, 5
- Replacing electrolytes such as potassium, phosphorous, and magnesium as needed 5
- Treating precipitating causes such as infection or insulin omission 3, 4, 5
- Considering bicarbonate therapy in very severe cases, although its use is controversial 7