What are the symptoms and treatment of Diabetic Ketoacidosis (DKA)?

Diabetic Ketoacidosis: Symptoms and Treatment

Clinical Presentation

DKA typically develops over hours to 24 hours and presents with a constellation of hyperglycemic and ketotic symptoms that require immediate recognition and treatment. 1

Classic Symptoms

Early symptoms include: 1

• Polyuria (excessive urination from osmotic diuresis)
• Polydipsia (excessive thirst)
• Polyphagia (excessive hunger)
• Weight loss (from fluid loss and catabolism)
• Weakness and fatigue

Progressive symptoms as DKA worsens: 1

• Nausea and vomiting (occurs in up to 25% of patients, may be coffee-ground appearance)
• Abdominal pain (specific to DKA, not seen in HHS)
• Dehydration with poor skin turgor
• Altered mental status ranging from confusion to lethargy (though patients are usually alert, unlike HHS)

Physical Examination Findings

Key signs to identify: 1

• Kussmaul respirations (deep, rapid breathing to compensate for metabolic acidosis)
• Fruity breath odor (from acetone) 2
• Tachycardia and hypotension (from volume depletion)
• Flushed face 2
• Hypothermia or normothermia despite infection (hypothermia is a poor prognostic sign) 1

Diagnostic Criteria

DKA is confirmed when all three criteria are present: 3

• Blood glucose >250 mg/dL 1
• Arterial pH <7.30 or serum bicarbonate <18 mEq/L 1
• Presence of ketones in blood or urine 3

---

Treatment Protocol

Initial Resuscitation (First Hour)

Begin aggressive fluid resuscitation immediately with isotonic saline at 15-20 mL/kg/hour to restore circulatory volume. 4, 5 This addresses the profound volume depletion from osmotic diuresis. 1

Critical pitfall: Do NOT start insulin if serum potassium is <3.3 mEq/L, as insulin drives potassium intracellularly and can cause life-threatening cardiac arrhythmias and death. 5, 2 First, aggressively replace potassium with 20-40 mEq/L added to IV fluids (using 2/3 KCl and 1/3 KPO4). 5

Insulin Therapy

Once potassium ≥3.3 mEq/L, start IV regular insulin with a bolus of 0.1 units/kg followed by continuous infusion at 0.1 units/kg/hour. 4, 5 Target a glucose decline of 50-75 mg/dL per hour. 5

Continue IV insulin until DKA fully resolves, regardless of glucose levels. 4 Resolution requires ALL of the following: 4

• Glucose <200 mg/dL
• Serum bicarbonate ≥18 mEq/L
• Venous pH >7.3
• Anion gap ≤12 mEq/L

Electrolyte Management

Add 20-30 mEq/L potassium to IV fluids once renal function is confirmed. 5 Monitor potassium closely every 2-4 hours, as total body potassium is depleted despite potentially normal initial serum levels. 6, 2

Target serum potassium of 4-5 mEq/L throughout treatment. 6 Insulin therapy continuously drives potassium into cells, creating ongoing risk of hypokalemia. 2

Monitoring Requirements

Check the following every 2-4 hours: 5

• Blood glucose
• Serum electrolytes (especially potassium)
• Venous pH
• Blood urea nitrogen and creatinine
• Serum osmolality

Obtain initial workup: 5

• Complete blood count
• Urinalysis and urine ketones
• Electrocardiogram (especially if hypokalemia present)
• Bacterial cultures (blood, urine, throat) if infection suspected
• Chest X-ray if clinically indicated

Transition to Subcutaneous Insulin

Administer basal insulin (glargine or detemir) 2-4 hours BEFORE stopping IV insulin to prevent rebound hyperglycemia and DKA recurrence. 5, 6 This is the most common error leading to DKA recurrence. 5

Once DKA resolves and the patient can eat, transition to a multiple-dose insulin schedule using short/rapid-acting plus intermediate/long-acting insulin. 4, 5

---

Special Considerations

Euglycemic DKA

Pregnant patients and those on SGLT2 inhibitors may present with glucose <200 mg/dL. 1 Risk factors for SGLT2 inhibitor-associated DKA include very-low-carbohydrate diets, prolonged fasting, dehydration, and excessive alcohol intake. 1

Bicarbonate Administration

Bicarbonate is NOT routinely recommended and should only be considered in patients with pH <6.9 and severe acidosis. 7 Most patients recover with insulin and fluids alone. 7

Precipitating Factors to Address

The most common trigger is infection. 1 Other precipitants include: 1

• Inadequate or omitted insulin doses
• New-onset type 1 diabetes
• Myocardial infarction
• Cerebrovascular accident
• Pancreatitis
• Medications (corticosteroids, thiazides, sympathomimetics)
• Alcohol abuse

Treat the underlying cause while managing DKA. 4

Prevention of Recurrence

Never stop or hold basal insulin even if the patient is not eating. 1 Provide detailed sick-day management instructions including: 1

• Measure urine or blood ketones when glucose >200 mg/dL or during illness
• Maintain hydration
• Continue basal insulin
• Contact diabetes care team immediately if concerned

Patients at highest risk for DKA include: 1

• Type 1 diabetes
• Younger age
• Prior DKA episodes
• Behavioral health conditions (depression, eating disorders)
• High A1C levels
• Social determinants limiting access to insulin