From the Guidelines
DKA stands for Diabetic Ketoacidosis, a serious and potentially life-threatening complication of diabetes that requires immediate medical attention. It occurs when the body cannot use glucose for energy because there isn't enough insulin, leading to the breakdown of fat for fuel instead, producing ketones that build up in the blood and make it acidic 1. DKA primarily affects people with type 1 diabetes but can occasionally occur in type 2 diabetes during severe illness. Symptoms include excessive thirst, frequent urination, nausea, vomiting, abdominal pain, weakness, fatigue, confusion, and a fruity breath odor.
Key Management Goals
- Restoration of circulatory volume and tissue perfusion
- Resolution of hyperglycemia
- Correction of electrolyte imbalance and acidosis
- Treatment of any correctable underlying cause of DKA, such as sepsis, myocardial infarction, or stroke 1
Treatment Approach
Treatment typically involves insulin therapy, fluid replacement, and electrolyte correction in a hospital setting, with continuous intravenous insulin being the standard of care for critically ill and mentally obtunded patients 1. Blood glucose and ketone levels must be closely monitored during treatment. There is no significant difference in outcomes for intravenous human regular insulin versus subcutaneous rapid-acting analogs when combined with aggressive fluid management for treating mild or moderate DKA 1.
Prevention
DKA can be prevented by regularly checking blood sugar levels, taking insulin as prescribed, and following sick day management plans when ill, including more frequent monitoring and never skipping insulin doses even when not eating. The use of bicarbonate in patients with DKA is generally not recommended as it made no difference in the resolution of acidosis or time to discharge 1.
From the Research
Definition of Diabetic Ketoacidosis (DKA)
- Diabetic ketoacidosis (DKA) is a serious complication of diabetes characterized by the triad of hyperglycemia, ketosis, and anion gap metabolic acidosis 2, 3.
- A diagnosis of DKA is 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) 2.
Symptoms and Signs of DKA
- The symptoms and signs of DKA are nonspecific, including fatigue, polydipsia, polyuria, weakness, weight loss, nausea, vomiting, and abdominal pain with tachycardia and tachypnea on exam 4.
- DKA may be precipitated by the catabolic stress of acute illness such as trauma, surgery, or infections 5.
Treatment and Management of DKA
- The mainstays of treatment include restoration of circulating volume, insulin therapy, electrolyte replacement, and treatment of any underlying precipitating event 2.
- Early diagnosis and management are paramount to improve patient outcomes, and awareness of the potential for DKA in patients with type 2 diabetes on sodium-glucose cotransporter-2 inhibitors is critical 5.
- Judicious fluid and electrolyte management, as well as delaying and/or reducing insulin infusion rates in the setting of severe hypokalemia, are important considerations in the treatment of DKA 6.