What is Diabetic Ketoacidosis (DKA)?

From the Guidelines

Diabetic Ketoacidosis (DKA) is a serious, potentially life-threatening complication of diabetes that requires immediate medical attention, characterized by high blood sugar, the buildup of ketones in the blood, and metabolic acidosis, and its management should be individualized based on a careful clinical and laboratory assessment, as stated in the most recent guidelines 1.

Definition and Pathophysiology

DKA occurs primarily in people with type 1 diabetes when the body cannot use glucose for energy due to insufficient insulin, forcing it to break down fat instead, producing ketones, which are acidic and cause the blood to become too acidic when they accumulate. This process is triggered by illness, infection, missed insulin doses, or undiagnosed diabetes.

Symptoms and Diagnosis

Common symptoms of DKA include excessive thirst, frequent urination, nausea, vomiting, abdominal pain, weakness, fatigue, confusion, fruity-smelling breath, and rapid breathing. The diagnosis of DKA is based on the presence of hyperglycemia, metabolic acidosis, and ketosis.

Treatment and Management

Treatment of DKA requires immediate medical attention and typically involves:

• Insulin administration, with continuous intravenous insulin being the standard of care in critically ill and mentally obtunded patients 1
• Fluid replacement to rehydrate the body
• Electrolyte replacement (particularly potassium, sodium, and chloride) to restore balance
• Blood glucose and ketone levels must be closely monitored during treatment
• Successful transition of patients from intravenous to subcutaneous insulin requires administration of basal insulin 2–4 h prior to the intravenous insulin being stopped 1

Prevention

Prevention of DKA involves:

• Regular insulin administration as prescribed
• Frequent blood sugar monitoring
• Seeking medical attention promptly when ill or when blood sugar remains consistently elevated
• Individuals at risk for DKA should measure urine or blood ketones in the presence of symptoms and potential precipitating factors 1

Key Considerations

• 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
• The use of bicarbonate in patients with DKA made no difference in the resolution of acidosis or time to discharge, and its use is generally not recommended 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. Hyperglycemia (too much glucose in the blood) may develop if your body has too little insulin Hyperglycemia can be brought about by any of the following: Omitting your insulin or taking less than your doctor has prescribed. In patients with type 1 or insulin-dependent diabetes, prolonged hyperglycemia can result in DKA (a life-threatening emergency) 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.

Diabetic Ketoacidosis (DKA) is a life-threatening emergency that can occur in patients with type 1 or insulin-dependent diabetes when they have prolonged hyperglycemia.

• The early signs of DKA include glycosuria and ketonuria.
• Symptoms of DKA usually come on gradually and may include:
  • Polydipsia
  • Polyuria
  • Loss of appetite
  • Fatigue
  • Dry skin
  • Abdominal pain
  • Nausea and vomiting
  • Compensatory tachypnea
  • Drowsy feeling
  • Flushed face
  • Thirst
  • Fruity odor on the breath DKA can be caused by omitting insulin or taking less than prescribed, and if left uncorrected, can lead to nausea, vomiting, stomach pain, dehydration, loss of consciousness, or death 2, 2.

From the Research

Definition and Diagnosis of Diabetic Ketoacidosis (DKA)

• Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 and type 2 diabetes resulting from an absolute or relative insulin deficiency 3.
• A diagnosis of DKA is confirmed when all of the three criteria are present: 'D', either elevated blood glucose levels or a family history of diabetes mellitus; 'K', the presence of high urinary or blood ketoacids; and 'A', a high anion gap metabolic acidosis 4.
• The traditional triad of hyperglycemia, metabolic acidosis, and elevated serum or urine ketones is used to diagnose DKA, but recent guidelines have de-emphasized hyperglycemia due to the increasing incidence of euglycemic DKA 3.

Symptoms and Risk Factors

• Common symptoms of DKA include polyuria, polydipsia, nausea, vomiting, abdominal pain, weight loss, severe fatigue, dyspnea, and preceding febrile illness 3.
• DKA can occur in patients of all ages and can be the initial presentation of diabetes, especially in young children 3.
• The use of sodium-glucose cotransporter-2 inhibitors modestly increases the risk of DKA and euglycemic DKA 3.

Treatment and Management

• The mainstays of treatment include restoration of circulating volume, insulin therapy, electrolyte replacement, and treatment of any underlying precipitating event 4.
• Fluid and electrolyte replacement, insulin, treatment of precipitating causes, and close monitoring to adjust therapy and identify complications are essential components of DKA treatment 3.
• Sodium bicarbonate administration in adult patients should be individualized and considered in a subset of patients with moderately severe acidemia who are at risk for worsening acidemia, particularly if hemodynamically unstable 5.
• In patients with DKA and a relatively low plasma potassium level, insulin administration may cause hypokalemia and cardiac arrhythmias, and potassium chloride should be administered intravenously to bring the plasma potassium level close to 4mmol/L before insulin administration 5.

Special Considerations and Controversies

• Management of DKA requires reversing metabolic derangements, correcting volume depletion, electrolyte imbalances, and acidosis while concurrently treating the precipitating illness 6.
• There are still controversies regarding certain aspects of DKA management, including optimal fluid resuscitation, rate and type of insulin therapy, potassium and bicarbonate replacement 6.
• Special patient factors and comorbidities, such as pregnancy, renal disease, congestive heart failure, acute coronary syndrome, older age, and use of sodium-glucose cotransporter-2 inhibitors, should receive more careful attention and consideration in DKA treatment 6.