What is the role of the Burch score in managing a patient with diabetic ketoacidosis (DKA)?

The Burch Score Has No Role in Managing Diabetic Ketoacidosis

The Burch score is not a recognized or validated tool in DKA management and should not be used. There is no mention of the Burch score in any major diabetes society guidelines, including the American Diabetes Association, American Association of Clinical Endocrinologists, or Endocrine Society recommendations for DKA management 1, 2.

What Actually Guides DKA Management

DKA management is guided by specific diagnostic criteria and resolution parameters, not scoring systems:

Diagnostic Criteria

• DKA is diagnosed when all three criteria are met: blood glucose >250 mg/dL, arterial pH <7.3, serum bicarbonate <15 mEq/L, and presence of ketonemia or ketonuria 2
• Laboratory evaluation should include plasma glucose, electrolytes with calculated anion gap, arterial blood gases, serum ketones, and complete blood count 1, 2

Resolution Criteria (What Actually Matters)

• DKA is resolved when: glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L 2
• These objective parameters guide treatment decisions, not any scoring system 2

The Evidence-Based Management Approach

Initial Treatment Protocol

• Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour during the first hour to restore intravascular volume 2
• Start continuous IV regular insulin at 0.1 units/kg/hour after confirming potassium >3.3 mEq/L 1, 2
• Target glucose decline of 50-75 mg/dL per hour 1, 2

Monitoring Parameters (Not Scores)

• Draw blood every 2-4 hours for serum electrolytes, glucose, BUN, creatinine, osmolality, and venous pH 1, 2
• Follow venous pH and anion gap to monitor resolution of acidosis 1, 2
• Direct measurement of β-hydroxybutyrate is the preferred method for monitoring ketosis 1

Critical Management Points

• Add dextrose when glucose reaches 250 mg/dL while continuing insulin infusion to ensure complete ketoacidosis resolution 2
• Maintain potassium between 4-5 mEq/L throughout treatment, as total body potassium depletion is universal in DKA 2
• Administer basal insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia and ketoacidosis recurrence 2

Common Pitfall to Avoid

Do not use unvalidated scoring systems or tools in DKA management. The condition requires objective laboratory parameters and clinical assessment, not composite scores 1, 2. Management decisions should be based on the specific resolution criteria outlined above and frequent laboratory monitoring 2.

Alternative for Mild-Moderate Uncomplicated DKA

• For hemodynamically stable, alert patients with mild-moderate DKA, subcutaneous rapid-acting insulin analogs combined with aggressive fluid management are equally effective, safer, and more cost-effective than IV insulin 2
• Continuous IV insulin remains the standard for critically ill and mentally obtunded patients 2