How is the severity of Diabetic Ketoacidosis (DKA) assessed and managed?

From the Guidelines

The severity of Diabetic Ketoacidosis (DKA) should be assessed through clinical evaluation and laboratory parameters, with management tailored to severity, as outlined in the most recent guidelines 1.

Assessment of DKA Severity

Assessment includes measuring blood glucose, confirming ketosis, acidosis, and evaluating hydration status, vital signs, and mental status.

• Blood glucose levels are typically >250 mg/dL
• Ketosis is confirmed through serum ketones or elevated anion gap
• Acidosis is defined by pH <7.3 and bicarbonate <18 mEq/L
• Hydration status, vital signs, and mental status are also crucial in determining the severity of DKA

Management of DKA

Management follows a stepwise approach beginning with:

• Fluid resuscitation using isotonic saline, typically 1-1.5 L in the first hour, then 250-500 mL/hr
• Insulin therapy, with continuous intravenous insulin being the standard of care in critically ill and mentally obtunded individuals with DKA or HHS 1
• Potassium replacement is crucial when levels fall below 5.3 mEq/L, targeting 4-5 mEq/L
• Once glucose reaches 200-250 mg/dL, dextrose should be added to IV fluids while continuing insulin to clear ketones
• Bicarbonate therapy is generally not recommended, as it has been shown to make no difference in the resolution of acidosis or time to discharge 1
• Frequent monitoring of glucose, electrolytes, and clinical status is essential
• The underlying trigger for DKA must be identified and treated, commonly infection, medication non-adherence, or new-onset diabetes
• Resolution is defined as glucose <200 mg/dL, bicarbonate >15 mEq/L, and venous pH >7.3, at which point transition to subcutaneous insulin can begin 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. 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.

La gravedad de la cetoacidosis diabética (DKA) se evalúa mediante pruebas de sangre y orina que muestran cantidades grandes de glucosa y cetonas. Los síntomas de la DKA pueden variar desde leves hasta graves y pueden incluir:

• Sentimiento de somnolencia
• Cara enrojecida
• Sed
• Pérdida de apetito
• Olor a frutas en el aliento
• Respiración pesada
• Pulso rápido
• Náuseas
• Vómitos
• Dolor abdominal
• Deshidratación
• Pérdida de conciencia
• Muerte Es importante buscar asistencia médica inmediata si se presentan síntomas de DKA. 2

From the Research

Dka Ses Ordinal Variable

Dka (Diabetic Ketoacidosis) severity is assessed using various criteria, including:

• Blood glucose levels
• Presence of high urinary or blood ketoacids
• High anion gap metabolic acidosis 3
• Serum bicarbonate level less than 18 mEq per L 4
• pH less than 7.3 4

Management of DKA

Management of DKA involves:

• Hospitalization for aggressive intravenous fluids, insulin therapy, electrolyte replacement, and identification and treatment of the underlying precipitating event 5
• Restoration of circulating volume, insulin therapy, electrolyte replacement, and treatment of any underlying precipitating event 3
• Fluid repletion and insulin administration to restore normal hemodynamic status while decreasing the metabolic acidosis 6
• Monitoring of glucose concentrations, vital signs, and electrolytes to prevent complications arising from the treatment of DKA 6

Prevention of DKA

Prevention of DKA is crucial and can be achieved through:

• Patient education programs focusing on adherence to insulin and self-care guidelines during illness 5
• Improved access to medical providers 5
• New approaches such as extended availability of phone services, use of telemedicine, and utilization of public campaigns 5
• Appropriate management of insulin and suppression of stress hormones to prevent metabolic decompensation in the stressed diabetic patient 7