What is diabetic ketoacidosis (DKA)?

From the Guidelines

Diabetic Ketoacidosis (DKA) Definition and Characteristics

Diabetic ketoacidosis (DKA) is a serious complication of diabetes characterized by hyperglycemia, metabolic acidosis, and ketosis 1. It typically occurs in patients with type 1 diabetes, but can also occur in those with type 2 diabetes, particularly during periods of stress or infection.

Key Features of DKA

• Hyperglycemia: Blood glucose level greater than 250 mg/dL
• Metabolic Acidosis: Venous pH less than 7.3
• Ketosis: Presence of ketones in the urine or blood
• Bicarbonate Level: Less than 18 mmol/L

Management Goals

The primary objectives in managing DKA include:

• Restoration of circulatory volume and tissue perfusion
• Resolution of hyperglycemia
• Correction of electrolyte imbalance and acidosis
• Treatment of any underlying cause of DKA, such as sepsis, myocardial infarction, or stroke 1

Treatment Approaches

Treatment typically involves:

• Administration of intravenous insulin, such as regular insulin at a dose of 0.1 units/kg/hour
• Fluid replacement with isotonic saline
• In some cases, particularly for mild or moderate DKA, subcutaneous rapid-acting insulin analogs may be used in combination with aggressive fluid management 1

Important Considerations

• Individualization of treatment based on careful clinical and laboratory assessment is crucial
• Bicarbonate use is generally not recommended as it has been shown to make no difference in the resolution of acidosis or time to discharge 1
• Transition from intravenous to subcutaneous insulin requires administration of basal insulin 2–4 hours prior to stopping intravenous insulin to prevent recurrence of ketoacidosis and rebound hyperglycemia 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 when 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 can include:
  • Heavy breathing
  • Rapid pulse
  • Nausea
  • Vomiting
  • Stomach pain
  • Dehydration
  • Loss of consciousness
  • Death 2

From the Research

Definition and Characteristics of Diabetic Ketoacidosis (DKA)

• Diabetic ketoacidosis (DKA) is a serious complication of diabetes characterized by the triad of hyperglycemia, metabolic acidosis, and ketosis 3, 4, 5.
• It is defined by blood sugar levels >250 mg/dl, arterial pH <7.3, and serum bicarbonate <18 mEq/L, along with the presence of ketones 3.
• DKA can also occur with blood glucose levels <200 mg/dl, known as euglycemic DKA, which can be caused by factors such as recent insulin use, decreased caloric intake, and the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors 3, 6.

Causes and Precipitating Factors of DKA

• Precipitating causes of DKA include infection, insulin omission, and substance abuse 5.
• Insulin allergy and anti-insulin antibodies can also induce DKA in individuals with type 2 diabetes mellitus 4.
• The use of SGLT2 inhibitors has been associated with an increased incidence of euglycemic DKA 6.

Clinical Presentation and Diagnosis of DKA

• Symptoms of DKA include general malaise, dyspnea, altered mental status, and abdominal pain 7.
• Diagnosis is based on the presence of hyperglycemia, metabolic acidosis, and ketosis, along with clinical symptoms 3, 4, 5.
• Euglycemic DKA can be challenging to diagnose due to the presence of normal blood glucose levels, and clinicians may be misled by pseudonormoglycemia 3.

Treatment and Management of DKA

• Treatment of DKA involves intravenous insulin and fluid replacement, as well as the concomitant treatment of precipitating factors 5.
• Aggressive fluid repletion and bicarbonate infusion may be necessary in severe cases 7.
• Improved patient education and home glucose and ketone monitoring may help decrease the number of hospital admissions due to DKA 5.