What are the signs of diabetic ketoacidosis (DKA) and how is it managed?

Signs of Diabetic Ketoacidosis and Precautions

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

Clinical Presentation

Classic Signs and Symptoms

DKA manifests with a constellation of symptoms that develop progressively:

• Metabolic symptoms: Polyuria, polydipsia, weight loss, and dehydration occur as hyperglycemia causes osmotic diuresis 1
• Gastrointestinal symptoms: Nausea, vomiting, and abdominal pain are common presenting features 1
• Respiratory signs: Kussmaul respirations (deep, rapid breathing) develop as the body attempts to compensate for metabolic acidosis 1
• Mental status: Patients are usually alert, though altered mental status can occur in severe cases 1
• Physical findings: Flushed face, fruity odor on breath (from acetone), drowsy feeling, and signs of volume depletion 2

Timeline of Development

• Standard DKA: Develops over hours to days 1
• Early symptoms: Come on gradually over hours or days, including drowsiness, flushed face, thirst, and loss of appetite 2
• Severe symptoms: Heavy breathing and rapid pulse indicate progression 2

Diagnostic Criteria

The diagnosis requires all three components:

• Hyperglycemia: Plasma glucose >250 mg/dL (though can be <200 mg/dL in euglycemic DKA) 1, 3
• Metabolic acidosis: Arterial pH <7.30 and serum bicarbonate <18 mEq/L 3
• Ketosis: Positive serum and urine ketones with elevated anion gap 3

Critical Precautions and Risk Factors

High-Risk Populations

Type 1 diabetes with absolute insulin deficiency carries the highest risk, along with several other factors 1:

• Younger age 1
• Prior history of hyperglycemic or hypoglycemic crises 1
• Presence of other diabetes complications 1
• Behavioral health conditions (depression, bipolar disorder, eating disorders) 1
• Alcohol and/or substance use 1
• High A1C levels 1
• Social determinants of health 1

Special Populations Requiring Extra Vigilance

Pregnancy: Up to 2% of pregnancies with pregestational diabetes are complicated by DKA, with significant risk of feto-maternal harm 1:

• Euglycemic presentation: Pregnant individuals may present with glucose <200 mg/dL 1
• Mixed acid-base disturbances: Diagnosis may be hindered, particularly with hyperemesis 1
• Immediate action required: Pregnant individuals at risk should seek immediate medical attention if DKA is suspected 1

SGLT2 Inhibitor Users: These patients face unique risks 1:

• Relative risk of DKA is 2.46 in randomized trials and 1.74 in observational studies 1
• Euglycemic DKA: May present with normal or mildly elevated glucose (<200 mg/dL) and nonspecific symptoms 1
• Specific triggers: Very-low-carbohydrate diets, prolonged fasting, dehydration, excessive alcohol intake 1
• Surgical precaution: Discontinue SGLT2 inhibitors 3-4 days before elective procedures 1

Prevention Strategies

Patient Education and Monitoring

Never stop or hold basal insulin even when not eating—this is the most critical prevention measure. 1

• Provide detailed instructions on insulin dose adjustments during illness or fasting 1
• Measure urine or blood ketones when glucose exceeds 200 mg/dL, particularly with illness or missed insulin doses 1
• Contact diabetes care team immediately if concerned about DKA 1

Early Warning Signs Requiring Action

Patients should seek immediate medical attention if experiencing 1:

• Inability to tolerate oral hydration
• Blood glucose levels not improving with insulin administration
• Altered mental status
• Any signs of worsening illness

Home Management of Mild DKA (When Appropriate)

Patients who are hemodynamically stable, cognitively intact, able to tolerate oral hydration, and able to administer subcutaneous insulin may attempt home management with 1:

• Frequent blood glucose and ketone monitoring
• Noncaloric hydration
• Subcutaneous insulin administration

However, immediate medical attention is mandatory if any deterioration occurs. 1

Common Pitfalls to Avoid

Clinical Management Errors

• Insulin interruption: Never stop basal insulin during illness or fasting, even if not eating 1
• Delayed recognition: Be aware that early warning symptoms may be less pronounced in patients with long-standing diabetes, diabetic neuropathy, or those on beta-blockers 2
• Euglycemic DKA: Don't rule out DKA based on normal glucose alone, especially in pregnancy or SGLT2 inhibitor use 1
• Inadequate patient education: Failure to counsel high-risk patients on signs, symptoms, and when to seek care 1

Monitoring Gaps

• Insufficient ketone testing: Patients at risk should have access to urine or blood ketone testing supplies 1
• Lack of sick-day protocols: All insulin-treated patients need clear instructions for illness management 1
• Poor access to care: Readily available clinical support helps prevent emergency department visits through early intervention 1