From the Guidelines
The criteria for mild, moderate, and severe diabetic ketoacidosis (DKA) are primarily based on the severity of acidosis, with mild DKA defined as a venous pH 7.3 and bicarbonate 15 mmol/l, moderate DKA as a pH 7.2 with a bicarbonate 10, and severe DKA as a pH 7.1 and bicarbonate 5, as stated in the American Diabetes Association's guidelines 1. The classification of DKA into mild, moderate, and severe is crucial for determining the appropriate treatment approach and setting.
- Mild DKA is characterized by a venous pH of 7.3 and a bicarbonate level of 15 mmol/l, indicating a less severe metabolic acidosis.
- Moderate DKA presents with a pH of 7.2 and a bicarbonate level of 10, suggesting a more significant acidosis.
- Severe DKA is defined by a pH of 7.1 and a bicarbonate level of 5, indicating a life-threatening condition that requires intensive care management. These criteria, as outlined in the study published in Diabetes Care 1, help clinicians assess the severity of DKA and tailor treatment accordingly, including fluid resuscitation, insulin therapy, and electrolyte replacement, to minimize morbidity and mortality. Key factors in managing DKA include close monitoring of patients, particularly those with severe DKA, who are at a higher risk for complications and require more intensive care, as noted in the guidelines 1.
From the Research
Criteria for Diabetic Ketoacidosis (DKA) Severity
The severity of DKA can be classified into mild, moderate, and severe based on the American Diabetes Association (ADA) guidelines 2. The criteria for each severity level are as follows:
- Mild DKA:
- Plasma glucose concentration above 250 mg per dL
- pH level between 7.25 and 7.30
- Bicarbonate level between 15 and 18 mEq per L
- Moderate DKA:
- Plasma glucose concentration above 250 mg per dL
- pH level between 7.00 and 7.24
- Bicarbonate level between 10 and 14 mEq per L
- Severe DKA:
- Plasma glucose concentration above 250 mg per dL
- pH level below 7.00
- Bicarbonate level below 10 mEq per L
Diagnostic Criteria
A diagnosis of DKA requires the patient's plasma glucose concentration to be above 250 mg per dL, the pH level to be less than 7.30, and the bicarbonate level to be 18 mEq per L or less 3. Beta-hydroxybutyrate is a better measurement of the degree of ketosis than serum ketones.
Treatment and Management
The mainstay of treatment for DKA is appropriate fluid and insulin therapy 4. Low-dose intravenous infusion is now the accepted mode of insulin delivery for patients with this condition. Potassium replacement is almost always necessary, often requiring massive amounts of this ion due to the total body depletion seen with the development of ketoacidosis. Phosphate replacement may be needed if serum levels fall toward the lower limits of normal values, to avoid the potential adverse effects of phosphate depletion 5. Administration of bicarbonate is also controversial and should be reserved for patients whose pH is less than 7.0 to 7.1 and then it should be added to intravenous fluids, not given as an intravenous bolus 4.
Correlation between Severity and Outcomes
The ADA classification of severity of DKA correlates well with the duration of in-hospital stay, costs of care, requirement of ICU care, need for invasive ventilation, and mortality 2. This suggests that this classification system could be a valuable tool in predicting outcomes. Mild, moderate, and severe DKA accounted for 8%, 41%, and 51% of the patients, respectively, with corresponding mortality rates of 0%, 13.3%, and 26% 2.