What is the level of Diabetic Ketoacidosis (DKA)?

From the Guidelines

DKA level refers to the severity of diabetic ketoacidosis, which is categorized as mild, moderate, or severe based on laboratory values such as arterial pH, serum bicarbonate, and the presence of ketones in blood and urine, with the most recent guidelines 1 providing the framework for assessment and treatment. The severity of DKA is typically determined by the following criteria:

• Mild DKA: venous pH 7.3 and bicarbonate 15 mmol/l
• Moderate DKA: pH 7.2 with a bicarbonate 10
• Severe DKA: pH 7.1 and bicarbonate 5 These categories are based on the severity of the acidosis, with severe DKA being a potentially life-threatening condition that requires close physician monitoring and aggressive treatment 1. The management goals for DKA include restoration of circulatory volume and tissue perfusion, resolution of hyperglycemia, and correction of electrolyte imbalance and acidosis, with individualization of treatment based on a careful clinical and laboratory assessment 1. Some key points to consider in the treatment of DKA include:
• The use of continuous intravenous insulin in critically ill and mentally obtunded patients
• The transition from intravenous to subcutaneous insulin requires administration of basal insulin 2–4 h before the intravenous insulin is stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia 1
• The use of bicarbonate in patients with DKA is generally not recommended, as it has been shown to make no difference in the resolution of acidosis or time to discharge 1 Regular monitoring of glucose, electrolytes, and acid-base status is essential during treatment, and DKA severity assessment helps healthcare providers determine appropriate treatment intensity and setting, with severe cases requiring ICU admission 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. 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.

The DKA level is not explicitly defined in the provided drug labels. However, the labels describe the symptoms and consequences of Diabetic Ketoacidosis (DKA), which occurs when the body has too little insulin, leading to hyperglycemia.

• Key symptoms of DKA include:
  • Drowsy feeling
  • Flushed face
  • Thirst
  • Loss of appetite
  • Fruity odor on the breath
• Blood and urine tests show large amounts of glucose and ketones in patients with DKA 2. It is crucial to seek medical assistance immediately if DKA is suspected, as it can lead to severe consequences, including nausea, vomiting, stomach pain, dehydration, loss of consciousness, or death 2.

From the Research

DKA Level Classification

The level of Diabetic Ketoacidosis (DKA) can be classified based on its severity, which is crucial for determining the appropriate treatment and predicting patient outcomes. According to the American Diabetes Association (ADA) guidelines, DKA is classified into three levels of severity: mild, moderate, and severe 3.

Criteria for DKA Diagnosis

A diagnosis of DKA is confirmed when all of the three criteria are present:

• Elevated blood glucose levels or a family history of diabetes mellitus
• The presence of high urinary or blood ketoacids
• A high anion gap metabolic acidosis 4. Additionally, the traditional diagnosis of DKA is based on 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 or urine ketones 5, 6.

Severity of DKA

The severity of DKA is classified as follows:

• Mild DKA:
  • Blood glucose levels above 250 mg/dL
  • pH level between 7.25 and 7.30
  • Bicarbonate level between 15 and 18 mEq/L
• Moderate DKA:
  • Blood glucose levels above 250 mg/dL
  • pH level between 7.10 and 7.24
  • Bicarbonate level between 10 and 14 mEq/L
• Severe DKA:
  • Blood glucose levels above 250 mg/dL
  • pH level below 7.10
  • Bicarbonate level below 10 mEq/L 3.

Key Points

• The ADA classification of severity of DKA correlates well with the duration of in-hospital stay, costs of care, requirement of ICU care, need for invasive ventilation, and mortality 3.
• Early diagnosis and management are paramount to improve patient outcomes 4.
• The mainstays of treatment include restoration of circulating volume, insulin therapy, electrolyte replacement, and treatment of any underlying precipitating event 4, 7.