What is the treatment approach for Diabetic Ketoacidosis (DKA)?

Clinical Presentation of Diabetic Ketoacidosis (DKA)

DKA typically develops over hours to days and presents with polyuria, polydipsia, weight loss, dehydration, nausea, vomiting, abdominal pain, and Kussmaul respirations, with patients usually remaining alert unless severely ill. 1

Timeline and Mental Status

• DKA evolves rapidly over hours to days, distinguishing it from hyperosmolar hyperglycemic state (HHS) which develops over days to a week 1
• Patients are usually alert and oriented at presentation, unlike HHS where altered mental status is common 1
• Mental obtundation or coma indicates severe DKA requiring immediate ICU-level care 1, 2

Cardinal Symptoms

Hyperglycemic Symptoms

• Polyuria (excessive urination) from osmotic diuresis 1
• Polydipsia (excessive thirst) secondary to dehydration 1
• Weight loss from fluid depletion and catabolism 1
• Severe dehydration with poor skin turgor and dry mucous membranes 1

Gastrointestinal Manifestations

• Nausea and vomiting are prominent features 1
• Abdominal pain can mimic acute surgical abdomen 1
• These GI symptoms may be severe enough to delay diagnosis 3

Respiratory Signs

• Kussmaul respirations (deep, labored breathing) represent compensatory hyperventilation for metabolic acidosis 1
• Fruity odor on breath from acetone (though not always detectable) 4
• Dyspnea or shortness of breath 3

Additional Clinical Features

• Severe fatigue and weakness from metabolic derangements 3
• Flushed face from vasodilation 4
• Drowsiness as acidosis worsens 4
• Preceding febrile illness in many cases, as infection is a common precipitant 3

Important Clinical Caveats

Euglycemic DKA

• Glucose may be <200 mg/dL (11.1 mmol/L) in euglycemic DKA, particularly in pregnancy or with SGLT2 inhibitor use 1
• Do not rule out DKA based on glucose alone—ketoacidosis and metabolic acidosis are the defining features 3

Pregnancy-Specific Presentation

• Pregnant patients may present with euglycemic DKA and mixed acid-base disturbances 1
• Hyperemesis can mask or complicate the diagnosis 1
• Up to 2% of pregnancies with pregestational diabetes develop DKA, carrying significant feto-maternal risk 1

Hybrid Presentations

• One-third of hyperglycemic emergencies have overlapping DKA-HHS features, presenting with characteristics of both conditions 1

Progression to Severe DKA

As DKA worsens without treatment, expect:

• Disorientation and altered mental status 4
• Severe dehydration with hemodynamic instability 2
• Potential progression to seizures, unconsciousness, or death if untreated 4

Key Diagnostic Pitfalls to Avoid

• Do not dismiss DKA in type 2 diabetes patients, especially those on SGLT2 inhibitors where DKA occurs at 0.6-4.9 events per 1,000 patient-years 1
• Do not wait for severe hyperglycemia to diagnose DKA—focus on ketoacidosis and metabolic acidosis 3
• In pregnant patients, maintain high suspicion even with normal or mildly elevated glucose 1
• Abdominal pain may mimic surgical emergencies—check for ketoacidosis before pursuing surgical evaluation 1

Risk Factors Increasing Suspicion

When these clinical features are present in patients with the following risk factors, DKA should be strongly suspected:

• Type 1 diabetes or absolute insulin deficiency 1
• Younger age 1
• Prior history of hyperglycemic or hypoglycemic crises 1
• Behavioral health conditions (depression, bipolar disorder, eating disorders) 1
• Alcohol or substance use 1
• High A1C levels 1