What are the symptoms and management of diabetic ketoacidosis (DKA)?

Diabetic Ketoacidosis: Symptoms and Management

Clinical Presentation

The classic symptoms of DKA include polyuria, polydipsia, nausea, vomiting, abdominal pain, weight loss, severe fatigue, dyspnea, and often a preceding febrile illness. 1

Additional symptoms include:

• Drowsy feeling, flushed face, thirst, loss of appetite, and fruity odor on the breath 2
• Heavy breathing and rapid pulse in more severe cases 2
• Progressive symptoms developing over hours to days 2
• If uncorrected, progression to nausea, vomiting, stomach pain, dehydration, loss of consciousness, or death 2

Diagnostic Criteria

DKA is diagnosed by blood glucose >250 mg/dL, venous pH <7.3, serum bicarbonate <15 mEq/L, and moderate ketonuria or ketonemia. 3

Severity Classification:

• Mild DKA: pH 7.25-7.30, bicarbonate 15-18 mEq/L, alert mental status 3
• Moderate DKA: pH 7.00-7.24, bicarbonate 10-15 mEq/L, drowsy mental status 3
• Severe DKA: pH <7.00, bicarbonate <10 mEq/L, stupor/coma 3

Initial Laboratory Evaluation:

• Plasma glucose, blood urea nitrogen/creatinine, serum ketones (β-hydroxybutyrate preferred), electrolytes with calculated anion gap, osmolality, urinalysis, arterial blood gases, complete blood count, and electrocardiogram 4, 5
• Obtain bacterial cultures of urine, blood, and throat if infection is suspected 5, 3

Management Protocol

1. Fluid Resuscitation

Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour during the first hour. 4, 5, 3

• Continue aggressive fluid management to restore circulatory volume and improve tissue perfusion 4
• Total fluid replacement should be approximately 1.5 times the 24-hour maintenance requirements 5
• Add dextrose-containing fluids (5% dextrose with 0.45-0.75% NaCl) when blood glucose falls below 200-250 mg/dL to maintain adequate glucose levels while continuing insulin therapy to clear ketosis 4, 3

2. Insulin Therapy

Start continuous intravenous regular insulin infusion at 0.1 units/kg/hour without an initial bolus. 4

• Continue insulin infusion until complete resolution of ketoacidosis (pH >7.3, serum bicarbonate ≥18 mEq/L, and anion gap ≤12 mEq/L) regardless of glucose levels 4, 3
• Never interrupt insulin infusion when glucose levels fall; instead, add dextrose to prevent hypoglycemia while continuing insulin to clear ketosis 4

3. Electrolyte Management

Include 20-30 mEq/L potassium (2/3 KCl and 1/3 KPO₄) in the infusion once renal function is assured and serum potassium is <5.3 mEq/L. 4, 5

• Monitor potassium levels closely, as insulin therapy and correction of acidosis can cause hypokalemia 4, 5
• Maintain serum potassium between 4-5 mmol/L throughout treatment 4
• Bicarbonate administration is generally not recommended for patients with pH >6.9 4, 3

4. Monitoring During Treatment

Check blood glucose every 1-2 hours. 4

• Draw blood every 2-4 hours to determine serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH 4, 5, 3
• Follow venous pH and anion gap to monitor resolution of acidosis 4, 3

5. Transition to Subcutaneous Insulin

When DKA resolves (glucose stabilization, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L), administer basal insulin 2-4 hours BEFORE stopping the intravenous insulin to prevent recurrence of ketoacidosis. 4, 5, 3

• Start a multiple-dose insulin schedule using a combination of short/rapid-acting and intermediate/long-acting insulin when the patient can eat 5

Critical Pitfalls to Avoid

• Premature termination of insulin therapy before complete resolution of ketosis 4
• Interruption of insulin infusion when glucose levels fall without adding dextrose 4
• Stopping IV insulin without prior basal insulin administration—this is the most common error leading to DKA recurrence 5
• Inadequate monitoring and replacement of electrolytes, particularly potassium 4
• Relying solely on nitroprusside method to measure ketones, which doesn't detect β-hydroxybutyrate, the predominant ketone body in DKA 4, 3
• Failing to identify and treat the underlying precipitating cause of DKA 3

Special Considerations

For patients on SGLT2 inhibitors, be aware of euglycemic DKA where glucose may be normal or only mildly elevated despite severe ketoacidosis. 4, 1

• In euglycemic DKA, add dextrose-containing fluids earlier in treatment while continuing insulin therapy 4
• Direct measurement of β-hydroxybutyrate in blood is preferred over nitroprusside method 4, 3