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; noncompliance, 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, 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; add serum ketones if urine ketones present. |
DKA is characterized by hyperglycemia, an elevated anion gap* metabolic acidosis, and ketonemia. Dehydration and potassium deficits are often severe. |
Serum glucose is usually greater than 250 mg/dL (13.9 mmol/L) and less than 800 mg/dL (44.4 mmol/L). In certain instances (eg, insulin given prior to emergency department arrival), the glucose may be only mildly elevated. |
Additional testing is obtained based on clinical circumstances 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 and venous pH or bicarbonate every two to four hours until the patient is stable. |
Determine and treat any underlying cause of DKA (eg, pneumonia or urinary infection, myocardial ischemia). |
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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Give sodium bicarbonate to patients with pH below 6.90: |
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DKA: diabetic ketoacidosis; BUN: blood urea nitrogen; IV: intravenous; ECF: extracellular fluid; Na: sodium; K: potassium.
* 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, being 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.Do you want to add Medilib to your home screen?