Clinical features |
DKA usually evolves rapidly over a 24-hour period. |
The earliest symptoms of marked hyperglycemia are polyuria, polydipsia, and weight loss. Common, early signs of ketoacidosis include nausea, vomiting, abdominal pain, and hyperventilation. |
As hyperglycemia worsens, neurologic symptoms appear and may progress to include lethargy, focal deficits, obtundation, seizure, and coma. |
Common causes of DKA include: infection, nonadherence, inappropriate adjustment or cessation of insulin, new-onset diabetes mellitus, and myocardial ischemia. |
Evaluation and laboratory findings |
Assess vital signs, cardiorespiratory status, and mental status. |
Assess volume status: vital signs, skin turgor, oral mucosa, urine output. |
Obtain the following studies: serum glucose, urinalysis and urine ketones, serum electrolytes, BUN and creatinine, plasma osmolality, mixed venous blood gas, electrocardiogram, serum ketones (if available; may be measured initially or if urine ketones present). |
DKA is characterized by hyperglycemia, an elevated anion gap* metabolic acidosis, and ketonemia. Volume contraction and potassium deficits are often severe. |
Serum glucose is usually ≥200 mg/dL (11.1 mmol/L) and less than 800 mg/dL (44.4 mmol/L). In certain instances (eg, insulin given prior to emergency department arrival, SGLT2 inhibitor use), the glucose may be normal or only mildly elevated (<200 mg/dL [11.1 mmol/L]). |
Additional testing is obtained based on clinical circumstances to identify potential precipitants and may include: blood or urine cultures, lipase, chest radiograph. |
Management |
Stabilize the patient's airway, breathing, and circulation. |
Obtain large bore IV (≥16 gauge) access; monitor using a cardiac monitor, capnography, and pulse oximetry. |
Monitor serum glucose hourly, and basic electrolytes, BUN, creatinine, phosphorus, serum ketones, and venous pH or bicarbonate every 2 to 4 hours until the patient is stable. |
Identify and manage any underlying cause of DKA (eg, pneumonia or urinary tract infection, myocardial ischemia, intentional withholding of insulin). |
Replete ECF volume and free water deficits: |
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Replete potassium (K+) deficits: |
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Give insulin: |
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Bicarbonate and phosphate (rarely indicated) |
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BUN: blood urea nitrogen; DKA: diabetic ketoacidosis; ECF: extracellular fluid; IV: intravenous; K+: potassium; Na+: sodium; SGLT2: sodium-glucose cotransporter 2.
* Patients with DKA usually present with a serum anion gap greater than 20 mEq/L (normal range approximately 3 to 10 mEq/L). However, the increase in anion gap is variable and determined by several factors: the rate and duration of ketoacid production, the rate of metabolism of the ketoacids and their loss in the urine, and the volume of distribution of the ketoacid anions.
¶ Serum Na+ should be corrected for hyperglycemia; for each 100 mg/dL serum glucose exceeds 100 mg/dL (5.5 mmol/L), add 2 mEq to plasma Na+ for correction of Na+ value for hyperglycemia. A calculator to determine serum Na+ corrected for hyperglycemia is available separately in UpToDate.