Diabetic Ketoacidosis

Aka: Diabetic Ketoacidosis, DKA

1. See Also
   1. Diabetic Ketoacidosis Management in Adults
   2. Diabetic Ketoacidosis Management in Children
2. Precipitating Factors
   1. Uncontrolled or new onset Diabetes Mellitus
   2. Myocardial Infarction
   3. Pregnancy
   4. Infection
      1. Septic Shock
      2. Urinary Tract Infection
      3. Pneumonia
3. Symptoms
   1. Rapid onset of symptoms
   2. Weakness
   3. Nausea and Vomiting (50-80% of cases)
   4. Lethargy
   5. Abdominal Pain (30% of patients)
4. Signs
   1. Mental clouding
   2. Kussmaul breathing
   3. Acetone on breath
   4. Dehydration (often >10% dehydrated)
      1. Dry Skin with loss of Skin Turgor
      2. Eyes sunken
      3. Tachycardia and possibly Hypotension
   5. Temperature below normal
5. Labs
   1. Bedside Glucose
   2. Urinalysis
      1. Glucosuria
      2. Ketonuria
         1. Highly sensitive for Diabetic Ketoacidosis
         2. High Negative Predictive Value
         3. Negative Urine Ketone excludes DKA diagnosis
         4. Schwab (1999) Ann Emerg Med 34:342-6
   3. Chemistry Panel (Chem8)
      1. Serum Glucose increased (Hyperglycemia)
      2. Serum Sodium decreased (Hyponatremia)
      3. Serum Chloride depressed (Hypochloremia)
      4. Serum Bicarbonate depressed
      5. Anion Gap elevated (>10 to 12)
      6. Serum Phosphorus decreased (Hypophosphatemia)
      7. Serum Magnesium decreased (Hypomagnesemia)
      8. Serum Osmolality (calculate and measure if available)
         1. Should be >320 mOsm/kg if DKA present
   4. Arterial Blood Gas (ABG)
      1. Metabolic Acidosis
   5. Beta hydroxybutyrate or Serum Ketones
   6. Precipitating factor evaluation
      1. Complete Blood Count with differential
      2. Blood Culture
      3. Urine Culture
      4. Chest XRay
      5. Electrocardiogram (EKG)
         1. Indicated over age 40 or over 10 years of Diabetes
   7. Evaluation of Diabetes and Endocrine Status
      1. Hemoglobin A1C
      2. Anti-GAD65 Antibody (identifies Type I diabetics)
      3. Thyroid Stimulating Hormone (TSH)
6. Diagnostic Criteria: Hyperglycemia, Ketosis, Acidosis
   1. Blood Glucose exceeds 250 mg/dl
   2. Metabolic Acidosis
      1. Serum pH < 7.30
      2. Serum Bicarbonate < 15 meq/L
   3. Moderate Ketonuria or Ketonemia
      1. Serum Ketones exceed 1:2 dilution
   4. Anion Gap elevated
7. Evaluation: Severity
   1. Arterial pH
      1. Mild: 7.25 to 7.30
      2. Moderate: 7.00 to 7.24
      3. Severe: < 7.00
   2. Serum bicarbonate
      1. Mild: 15-18
      2. Moderate: 10 to 14
      3. Severe: < 10
   3. Mental status
      1. Mild: Alert
      2. Moderate: Drowsy
      3. Severe: Stupor
8. Indications for home management
   1. Mild Diabetic Ketoacidosis and
   2. Alert mental status and
   3. Taking oral fluids
9. Management
   1. See Diabetic Ketoacidosis Management in Adults
   2. See Diabetic Ketoacidosis Management in Children
10. Complications
    1. Metabolic Complications
       1. Severe Metabolic Acidosis
       2. Hypokalemia
       3. Hypoglycemia
       4. Hypocalcemia
    2. Non-metabolic Complications
       1. Septic Shock
       2. Hypovolemic Shock
       3. Vascular Thrombosis
       4. Pulmonary edema (aggressive rehydration)
       5. Cerebral edema
11. Prevention of Diabetic Ketoacidosis
    1. Diabetic action plan based on Blood Glucose Monitoring
       1. Home monitoring of beta hydroxybutyrate or ketones
       2. Plan for supplementing short acting Insulin
          1. Sick day Insulin coverage
          2. Liquid diets when sick
    2. Case management
       1. Diabetic educator
       2. Frequent phone contact
    3. Consider Insulin pump
12. References
    1. Orland in Stine (1994) Emergency Med, p. 204-5
    2. Chiasson (2003) CMAJ 168:859-66
    3. Kitabchi (2001) Diabetes Care 24:131-53
    4. Trachtenbarg (2005) Am Fam Physician 71(9): 1705-22
    5. Trence (2001) Endocrinol Metab Clin North Am 30:817-31