What are the diagnostic criteria and initial treatment for diabetic ketoacidosis (DKA)?

From the Guidelines

Diabetic ketoacidosis (DKA) is diagnosed when a patient has the triad of hyperglycemia (blood glucose >250 mg/dL), metabolic acidosis (arterial pH <7.3 and bicarbonate <18 mEq/L), and ketosis (elevated serum and urine ketones), and the initial treatment focuses on aggressive fluid resuscitation, insulin therapy, and electrolyte replacement, as recommended by the most recent guidelines 1.

Diagnostic Criteria

The diagnostic criteria for DKA include:

• Blood glucose >250 mg/dL
• Arterial pH <7.3
• Bicarbonate <18 mEq/L
• Moderate ketonuria or ketonemia

Initial Treatment

The initial treatment for DKA involves:

• Aggressive fluid resuscitation using 0.9% normal saline at 15-20 mL/kg/hr for the first hour (typically 1-2 L in adults)
• Start an intravenous insulin infusion at 0.1 units/kg/hr after fluid initiation
• Monitor potassium levels closely and begin replacement when levels fall below 5.2 mEq/L, aiming to maintain levels between 4-5 mEq/L
• Add dextrose to IV fluids when blood glucose reaches 200-250 mg/dL while continuing insulin to clear ketones
• Bicarbonate therapy is generally not recommended unless pH is <6.9

Monitoring and Resolution

Monitor blood glucose hourly, electrolytes every 2-4 hours, and assess for resolution of DKA by checking for normalized pH (>7.3), bicarbonate (>18 mEq/L), and anion gap. The underlying pathophysiology involves insulin deficiency leading to increased lipolysis, ketogenesis, and metabolic acidosis, which requires both insulin to stop ketone production and fluids to correct dehydration and electrolyte imbalances, as supported by recent studies 1. Some key points to consider in the treatment of DKA include:

• The use of bicarbonate in people with DKA made no difference in the resolution of acidosis or time to discharge, and its use is generally not recommended 1
• The administration of a low dose of basal insulin analog in addition to intravenous insulin infusion may prevent rebound hyperglycemia without increased risk of hypoglycemia 1
• Successful transition from intravenous to subcutaneous insulin requires administration of basal insulin 2–4 h before the intravenous insulin is stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia 1

From the FDA Drug Label

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. Eating significantly more than your meal plan suggests. Developing a fever, infection, or other significant stressful situation. 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. With DKA, blood and urine tests show large amounts of glucose and ketones. Heavy breathing and a rapid pulse are more severe symptoms If uncorrected, prolonged hyperglycemia or DKA can lead to nausea, vomiting, stomach pain, dehydration, loss of consciousness, or death.

The diagnostic criteria for Diabetic Ketoacidosis (DKA) include:

• Hyperglycemia (high blood glucose)
• Presence of ketones in the blood and urine
• Symptoms such as:
  • Drowsy feeling
  • Flushed face
  • Thirst
  • Loss of appetite
  • Fruity odor on the breath
  • Heavy breathing
  • Rapid pulse The initial treatment for DKA is not explicitly stated in the provided drug labels, but it is implied that intravenous administration of insulin and correction of hyperglycemia are important components of treatment 2.

From the Research

Diagnostic Criteria for Diabetic Ketoacidosis (DKA)

• 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
  • 'A', a high anion gap metabolic acidosis 3
• Traditionally, DKA has been diagnosed by the triad of hyperglycemia (blood glucose greater than 250 mg/dL), metabolic acidosis (pH less than 7.3, serum bicarbonate less than 18 mEq/L, anion gap greater than 10 mEq/L), and elevated serum (preferred) or urine ketones 4
• Hyperglycemia has been de-emphasized in recent guidelines because of the increasing incidence of euglycemic DKA 4

Initial Treatment for Diabetic Ketoacidosis (DKA)

• The mainstays of treatment include restoration of circulating volume, insulin therapy, electrolyte replacement and treatment of any underlying precipitating event 3
• Treatment involves fluid and electrolyte replacement, insulin, treatment of precipitating causes, and close monitoring to adjust therapy and identify complications 4
• Appropriate treatment includes administering intravenous fluids and insulin, and monitoring glucose and electrolyte levels 5
• Intravenous insulin and fluid replacement are the mainstays of therapy, with careful monitoring of potassium levels 6
• Proper management of DKA requires hospitalization for aggressive intravenous fluids, insulin therapy, electrolyte replacement as well as identification and treatment of the underlying precipitating event along with frequent monitoring of patient's clinical and laboratory states 7

Additional Tests and Evaluations

• Electrolytes, phosphate, blood urea nitrogen, creatinine, urinalysis, complete blood cell count with differential, A1C, and electrocardiography should be evaluated for all patients diagnosed with DKA to identify causes and complications of DKA 4
• Amylase, lipase, hepatic transaminase levels, troponin, creatine kinase, blood and urine cultures, and chest radiography are additional tests to consider 4
• 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 diabetic ketoacidosis from hyperosmolar hyperglycemic state, gastroenteritis, starvation ketosis, and other metabolic syndromes, and can assist in diagnosing comorbid conditions 5