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, 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 that accumulate and cause the blood to become too acidic. This condition typically develops when insulin levels are very low or absent, often 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
• Rapid breathing Diagnosis is based on clinical presentation and laboratory findings, including high blood glucose levels, presence of ketones in the blood or urine, and metabolic acidosis.

Treatment and Management

Treatment of DKA involves insulin administration, fluid replacement to correct dehydration, and electrolyte replacement (particularly potassium, sodium, and chloride), with the goal of restoring circulatory volume and tissue perfusion, resolving hyperglycemia, and correcting electrolyte imbalance and acidosis, as recommended in the latest guidelines 1. Key aspects of treatment include:

• Continuous intravenous insulin in critically ill patients
• Administration of basal insulin 2–4 hours prior to stopping intravenous insulin to prevent recurrence of ketoacidosis and rebound hyperglycemia
• Aggressive fluid management
• Electrolyte replacement
• Monitoring of blood glucose and ketone levels

Complications and Prevention

DKA can lead to severe complications, including cerebral edema, hypoxemia, and noncardiogenic pulmonary edema, if not promptly and properly treated. Prevention measures include better access to medical care, proper education, and effective communication with a healthcare provider during intercurrent illness, as well as sick-day management strategies to prevent the development of DKA 1.

From the Research

Definition and Overview of Diabetic Ketoacidosis (DKA)

• Diabetic Ketoacidosis (DKA) is a life-threatening complication of diabetes that occurs when the body produces high levels of blood acids called ketones 2.
• It is characterized by the triad of hyperglycemia, metabolic acidosis, and elevated serum or urine ketones, although recent guidelines have de-emphasized hyperglycemia due to the increasing incidence of euglycemic DKA 2.
• DKA can occur in patients with type 1 and type 2 diabetes, and it is the most common hyperglycemic emergency in patients with diabetes mellitus 3.

Causes and Precipitating Factors of DKA

• Infection is the most common precipitating cause of DKA, occurring in 30-50% of cases, with urinary tract infection and pneumonia being the most common infections 3.
• Other precipitating causes include intercurrent illnesses, psychological stress, and non-compliance with insulin therapy 3.
• New onset of diabetes, insulin omission, and misdiagnosis with consequent inappropriate insulin prescription are also important factors in type 1 diabetes mellitus (T1DM) 4.
• In type 2 diabetes mellitus (T2DM), the main causes of DKA are infection and excessive soft drink consumption 4.

Clinical Presentation and Diagnosis of DKA

• The clinical presentation of DKA includes symptoms such as polyuria, polydipsia, nausea, vomiting, abdominal pain, weight loss, severe fatigue, dyspnea, and preceding febrile illness 2.
• Vomiting is a characteristic symptom in T1DM DKA, while T2DM DKA patients often present with generalized malaise or decreased level of consciousness 4.
• Diagnosis of DKA involves evaluating electrolytes, phosphate, blood urea nitrogen, creatinine, urinalysis, complete blood cell count with differential, A1C, and electrocardiography to identify causes and complications of DKA 2.

Treatment and Management of DKA

• Treatment of DKA involves fluid and electrolyte replacement, insulin, treatment of precipitating causes, and close monitoring to adjust therapy and identify complications 2.
• Successful treatment of DKA requires frequent monitoring of patients, correction of hypovolemia and hyperglycemia, replacement of electrolyte losses, and careful search for the precipitating cause 3.
• The use of sodium-glucose cotransporter-2 inhibitors modestly increases the risk of DKA and euglycemic DKA, and prevention strategies include identifying diabetes before DKA develops, educating patients to manage high-risk situations, and ensuring uninterrupted access to therapies for diabetes 2.