What is the workup for Diabetic Ketoacidosis (DKA)?

From the Guidelines

The workup for diabetic ketoacidosis (DKA) should include a comprehensive assessment of the patient's clinical status, laboratory values, and identification of precipitating factors, with a focus on serum glucose, serum ketones, arterial or venous blood gas, anion gap calculation, electrolytes, and urinalysis, as outlined in the most recent guidelines 1. The initial evaluation should begin with a thorough history and physical examination, focusing on symptoms like polyuria, polydipsia, abdominal pain, nausea, vomiting, and altered mental status. Vital signs should be monitored closely, particularly for signs of dehydration and Kussmaul respirations.

• Key laboratory tests include: + Serum glucose (typically >250 mg/dL) + Serum ketones + Arterial or venous blood gas to assess acidosis (pH <7.3) + Anion gap calculation (elevated >12 mEq/L) + Electrolytes (particularly potassium, sodium, chloride, and bicarbonate) + Complete blood count + Renal function tests + Urinalysis for glucose and ketones
• Additional tests should include serum osmolality, phosphate, magnesium, and cardiac enzymes if indicated.
• An electrocardiogram should be performed to assess for cardiac abnormalities related to electrolyte disturbances.
• Imaging studies may be necessary if infection is suspected as a precipitating factor. The workup should also include identification of potential triggers such as infection, medication non-compliance, new-onset diabetes, myocardial infarction, stroke, pancreatitis, or medication effects (particularly glucocorticoids, thiazide diuretics, and atypical antipsychotics) 1. The most recent guidelines recommend individualization of treatment based on a careful clinical and laboratory assessment, with a focus on restoration of circulatory volume and tissue perfusion, resolution of ketoacidosis, and correction of electrolyte imbalance and acidosis 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 workup for Diabetic Ketoacidosis (DKA) includes:

• Blood tests to show large amounts of glucose
• Urine tests to show large amounts of ketones Monitoring for symptoms such as:
• Drowsy feeling
• Flushed face
• Thirst
• Loss of appetite
• Fruity odor on the breath
• Heavy breathing
• Rapid pulse 2

From the Research

Diagnosis of Diabetic Ketoacidosis (DKA)

• DKA is diagnosed when all three criteria are present: 'D' (elevated blood glucose levels or a family history of diabetes mellitus), 'K' (presence of high urinary or blood ketoacids), and '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

Evaluation of DKA

• 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
• Additional tests to consider include amylase, lipase, hepatic transaminase levels, troponin, creatine kinase, blood and urine cultures, and chest radiography 4

Treatment of 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
• Current acceptable treatment of DKA includes adequate fluid replacement, low-dose insulin therapy at frequent intervals, adequate potassium replacement from the time of first insulin therapy with ECG monitoring, and bicarbonate replacement if pH is less than 7.1 5

Management Considerations

• The severity of DKA is classified based on the level of acidosis present rather than absolute glucose level 6
• The management of severe DKA involves assessing and treating the inciting event, fluid hydration, insulin, and potassium repletion 6
• Close monitoring is necessary to prevent complications that can occur 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 (SGLT2) inhibitors, should receive careful attention and consideration 7