What is the evaluation for Diabetic Ketoacidosis (DKA)?

From the Guidelines

Evaluation of diabetic ketoacidosis (DKA) should prioritize assessment of blood glucose, anion gap, arterial pH, serum bicarbonate, urine and serum ketones, and electrolytes, as well as identification of underlying precipitating factors, as outlined in the 2024 standards of care in diabetes 1. When evaluating DKA, initial laboratory tests should include:

• A comprehensive metabolic panel
• Complete blood count
• Venous or arterial blood gas
• Urinalysis
• Calculation of the anion gap (sodium - [chloride + bicarbonate]), with values greater than 12 mEq/L suggesting DKA, as individualization of treatment based on a careful clinical and laboratory assessment is needed 1. Key components of the evaluation include:
• Blood glucose levels, which typically exceed 250 mg/dL
• Arterial pH, which is less than 7.3
• Serum bicarbonate, which is below 18 mEq/L
• Presence of ketones in urine or serum
• Assessment for precipitating factors such as infection, medication non-adherence, myocardial infarction, stroke, or pancreatitis, as treatment goals include restoration of circulatory volume and tissue perfusion, resolution of ketoacidosis, and correction of electrolyte imbalance and acidosis 1. Monitoring potassium levels closely is crucial, as total body potassium is depleted despite potentially normal or elevated initial serum levels, and serial measurements of glucose, electrolytes, and pH are essential to track response to treatment 1. Evaluation of hydration status through vital signs, skin turgor, and mucous membranes is also important, as aggressive fluid management is a key component of DKA treatment, and the use of bicarbonate is generally not recommended, as several studies have shown that it makes no difference in the resolution of acidosis or time to discharge 1.

From the Research

DKA Evaluation

DKA evaluation involves several key components, including:

• Diagnosis based on hyperglycemia, metabolic acidosis, and elevated serum or urine ketones 2
• Identification of symptoms such as polyuria, polydipsia, nausea, vomiting, abdominal pain, weight loss, severe fatigue, dyspnea, and preceding febrile illness 2, 3
• Laboratory tests, including:
  • Electrolytes, phosphate, blood urea nitrogen, creatinine, urinalysis, complete blood cell count with differential, A1C, and electrocardiography 2
  • Amylase, lipase, hepatic transaminase levels, troponin, creatine kinase, blood and urine cultures, and chest radiography 2
• Calculation of anion gap and osmolar gap to differentiate DKA from other metabolic syndromes 3

Diagnostic Criteria

The diagnostic criteria for DKA include:

• Hyperglycemia (blood glucose greater than 250 mg/dL) 2, 3
• Metabolic acidosis (pH less than 7.3, serum bicarbonate less than 18 mEq/L, anion gap greater than 10 mEq/L) 2, 3
• Elevated serum or urine ketones 2, 4
• The presence of all three criteria: 'D' (elevated blood glucose levels or a family history of diabetes mellitus), 'K' (high urinary or blood ketoacids), and 'A' (high anion gap metabolic acidosis) 4

Treatment and Prevention

Treatment of DKA involves:

• Fluid and electrolyte replacement 2, 4
• Insulin therapy 2, 4
• Treatment of precipitating causes 2, 4
• Close monitoring to adjust therapy and identify complications 2 Prevention strategies include:
• Identifying diabetes before DKA develops 2
• Educating patients to manage high-risk situations 2
• Ensuring uninterrupted access to therapies for diabetes 2