From the Guidelines
DKA, or diabetic ketoacidosis, is a serious complication of diabetes that requires immediate medical attention, and the most recent and highest quality study 1 recommends individualization of treatment based on a careful clinical and laboratory assessment.
Diagnosis and Treatment
DKA occurs when the body cannot use glucose for energy due to insufficient insulin, causing it to break down fat for fuel and produce ketones, which make the blood acidic.
- The diagnostic criteria for DKA include blood glucose >250 mg/dL, venous pH <7.3, and moderate ketonuria or ketonemia, as stated in the study 1.
- Treatment involves hospitalization for IV fluids to rehydrate, insulin therapy, and electrolyte replacement, particularly potassium, as levels often drop with treatment.
- The study 1 suggests that continuous intravenous insulin is the standard of care for critically ill and mentally obtunded patients with DKA or hyperosmolar hyperglycemic state.
Management Goals
- Restoration of circulatory volume and tissue perfusion
- Resolution of ketoacidosis
- Correction of electrolyte imbalance and acidosis
- Treatment of any correctable underlying cause of DKA, such as sepsis, myocardial infarction, or stroke
Prevention
- Regular insulin administration
- Frequent blood glucose monitoring
- Checking for ketones during illness
Monitoring and Follow-up
- Blood glucose should be monitored hourly, with a target reduction of 50-75 mg/dL per hour
- Once glucose reaches 200-250 mg/dL, dextrose should be added to prevent hypoglycemia while continuing insulin to clear ketones
- The underlying cause of DKA must be identified and treated, commonly infection, missed insulin doses, or newly diagnosed diabetes, as stated in the study 1.
From the FDA Drug Label
Hyperglycemia (High Blood Sugar) and Diabetic Ketoacidosis (DKA) 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. Eating significantly more than your meal plan suggests. Developing a fever, infection, or other significant stressful situation. 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. Heavy breathing and a rapid pulse are more severe symptoms If uncorrected, prolonged hyperglycemia or DKA can lead to nausea, vomiting, stomach pain, dehydration, loss of consciousness, or death.
Diabetic Ketoacidosis (DKA) is a life-threatening emergency that can occur in patients with type 1 or insulin-dependent diabetes if they have prolonged hyperglycemia.
- 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
- Fruity odor on the breath
- Severe symptoms of DKA include:
- Heavy breathing
- Rapid pulse
- Nausea
- Vomiting
- Stomach pain
- Dehydration
- Loss of consciousness
- Death It is essential to obtain medical assistance immediately if DKA is suspected 2.
From the Research
Definition and Characteristics of DKA
- Diabetic ketoacidosis (DKA) is a hyperglycemic emergency that poses a significant risk for death in patients with diabetes mellitus 3.
- DKA is characterized by hyperglycemia, metabolic acidosis, and ketosis 3, 4.
Management of DKA
- Proper management of DKA requires hospitalization for aggressive intravenous fluids, insulin therapy, electrolyte replacement, and identification and treatment of the underlying precipitating event 3.
- Fluid resuscitation is a cornerstone of DKA management, with traditional guidelines recommending isotonic normal saline (NS) for initial volume replacement 5.
- However, recent studies suggest that large volumes of NS may lead to undesirable outcomes such as hyperchloremic metabolic acidosis, and balanced crystalloid solutions like lactated Ringers may result in better outcomes 5, 6.
Precipitating Causes and Prevention of DKA
- The most common precipitating causes for DKA include infections, new diagnosis of diabetes, and nonadherence to insulin therapy 3.
- Clinicians should be aware of the occurrence of DKA in patients prescribed sodium-glucose co-transporter 2 inhibitors 3.
- Future episodes of DKA can be reduced through patient education programs focusing on adherence to insulin and self-care guidelines during illness and improved access to medical providers 3.
Treatment Outcomes and Complications
- Large-volume resuscitation with isotonic NS in DKA patients is associated with increased ICU length of stay, prolonged insulin infusion, and a higher incidence of non-anion gap metabolic acidosis 5.
- The use of near-patient testing of capillary beta-hydroxybutyrate (b-OHB) using a ketone meter can aid in managing and preventing DKA 4.
- Evidence remains scarce or conflicting for the use of "two-bag" compared to conventional "one-bag" fluid, and rates of fluid administration, especially for adult patients 6.