From the Guidelines
Diabetic ketoacidosis (DKA) is diagnosed when a patient has the triad of hyperglycemia (blood glucose >250 mg/dL), metabolic acidosis (venous pH <7.3 and serum bicarbonate <15 mEq/L), and ketosis (moderate ketonuria or ketonemia) as stated in the most recent and highest quality study 1. To confirm DKA, laboratory tests should include:
- A comprehensive metabolic panel
- Complete blood count
- Urinalysis for ketones
- Serum ketones (particularly beta-hydroxybutyrate)
- Venous blood gas
- Hemoglobin A1C The severity of DKA is classified based on venous pH:
- Mild (7.25-7.30)
- Moderate (7.00-7.24)
- Severe (<7.00) Additional diagnostic criteria include an anion gap >10 mEq/L and often signs of dehydration. Common precipitating factors that should be investigated include:
- Infection
- Medication non-compliance
- New-onset diabetes
- Myocardial infarction
- Stroke
- Pancreatitis
- Certain medications like glucocorticoids or SGLT2 inhibitors Clinical presentation typically includes:
- Polyuria
- Polydipsia
- Nausea
- Vomiting
- Abdominal pain
- In severe cases, altered mental status or Kussmaul respirations (deep, rapid breathing) Early diagnosis is crucial as DKA has significant mortality if not promptly treated with insulin, fluids, and electrolyte replacement, as supported by 1. The most critical step in managing DKA is prompt recognition and treatment to prevent morbidity and mortality, and improve quality of life.
From the Research
DKA Diagnosis
- Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 and type 2 diabetes, resulting from an absolute or relative insulin deficiency 2.
- The traditional diagnosis of DKA is based on the triad of hyperglycemia, metabolic acidosis, and elevated serum or urine ketones 2, 3.
- However, recent guidelines have de-emphasized hyperglycemia due to the increasing incidence of euglycemic DKA 2.
- A diagnosis of DKA can be confirmed 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) 4.
Diagnostic Criteria
- Hyperglycemia: blood glucose greater than 250 mg/dL 2, 3
- Metabolic acidosis: pH less than 7.3, serum bicarbonate less than 18 mEq/L, anion gap greater than 10 mEq/L 2, 3
- Elevated serum or urine ketones 2, 3
- Beta-hydroxybutyrate is a better measurement of the degree of ketosis than serum ketones 3
Additional Tests
- 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 2
- Amylase, lipase, hepatic transaminase levels, troponin, creatine kinase, blood and urine cultures, and chest radiography are additional tests to consider 2
- Serum potassium, sodium, chloride, calcium, magnesium, and phosphorus levels should be monitored 5