From the Guidelines
The workup for diabetic ketoacidosis (DKA) should begin with a thorough clinical assessment including vital signs, mental status evaluation, and hydration assessment, followed by laboratory testing with serum glucose, serum ketones, arterial blood gas analysis, and other essential tests as outlined in the most recent guidelines 1. The clinical assessment should include evaluation of the patient's hydration status, mental status, and vital signs.
- Laboratory testing is essential and should include:
- Serum glucose (typically >250 mg/dL)
- Serum ketones
- Arterial blood gas analysis showing metabolic acidosis (pH <7.3)
- Bicarbonate <18 mEq/L
- Anion gap >10-12
- Complete blood count
- Comprehensive metabolic panel
- Urinalysis for ketones and glucose
- Serum osmolality
- HbA1c
- An ECG should be performed to assess for cardiac abnormalities related to electrolyte disturbances.
- Imaging studies like chest X-ray may be indicated if infection is suspected as a precipitating factor.
- Point-of-care testing for beta-hydroxybutyrate provides a more accurate assessment of ketosis than urine ketones.
- Patients should also be evaluated for precipitating factors such as infection, medication non-compliance, myocardial infarction, stroke, trauma, or new-onset diabetes. This comprehensive workup allows for prompt diagnosis and guides appropriate management with IV fluids, insulin therapy, and electrolyte replacement, particularly potassium, which should be monitored closely as levels often drop rapidly with treatment despite initial elevations due to acidosis, as recommended in the latest guidelines 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 and Evaluation
- Diabetic ketoacidosis (DKA) is diagnosed by the triad of hyperglycemia, metabolic acidosis, and elevated serum or urine ketones 3
- However, hyperglycemia has been de-emphasized in recent guidelines due to the increasing incidence of euglycemic DKA 3
- 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 3
- Additional tests to consider include amylase, lipase, hepatic transaminase levels, troponin, creatine kinase, blood and urine cultures, and chest radiography 3
Treatment
- Treatment involves fluid and electrolyte replacement, insulin, treatment of precipitating causes, and close monitoring to adjust therapy and identify complications 3
- Insulin is given by intravenous drip at an initial rate of about 0.1 u per kg per hour 4
- The initial hydrating fluid is 5 percent glucose in 0.45 percent saline plus 40 mEq of potassium chloride or buffered potassium phosphate, given at a rate of 250 mL per hour 4
- Sodium bicarbonate and blood gas monitoring are controversial and may not be necessary in all cases 5
Management
- 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 careful attention and consideration 6