Diabetic Ketoacidosis

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• Diabetic ketoacidosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ifrah Fatima, M.B.B.S[2]

Overview

This section provides a short and straight to the point overview of the disease or symptom. The first sentence of the overview must contain the name of the disease.

Causes

The following are the causes of diabetic ketoacidosis (DKA):

Common Causes

• Lack of insulin
  • New diagnosis of Type 1 diabetes mellitus
  • Non compliance with insulin in a known diabetic patient
  • Insufficient insulin dose in hospitalized patients
• Drugs:
  • Antipsychotic agents (clozapine, olanzapine, risperidone)
  • Illicit drugs (cocaine and alcohol)
  • Corticosteroids
  • Glucagon
  • Interferon
  • Pentamidine
  • Sympathomimetic agents (albuterol, dopamine, dobutamine, terbutaline, ritodrine, thiazide diuretics)

• Infections:
  • Pneumonia
  • Sepsis
  • Urinary tract infection

Less common causes

Nonadherence to insulin treatment plans:

• Body image issues
• Financial problems
• Psychological factors

Physiological stressors:

• Acromegaly
• Thrombosis
• Cerebrovascular accident
• Cushing's disease
• Hemochromatosis
• Myocardial infarction
• Pancreatitis
• Pregnancy
• Psychological stress
• Shock/hypovolemia
• Trauma

Diagnosis

• The diagnosis of diabetic ketoacidosis is made in the presence of:
  • Hyperglycemia- Plasma glucose > 250 mg/dL
  • Anion gap metabolic acidosis- pH < 7.3; Serum bicarbonate < 15 mEq/L
  • Ketonemia/ Ketonuria
• Shown below is a table summarizing the diagnosis of Diabetic ketoacidosis according the the American Diabetes Association (ADA) guidelines.

Parameter	Lab value
Plasma glucose	250-600 mg/dL or > 13.9 mmol/L
Arterial pH	<7.3
Serum bicarbonate	< 18 mEq/L
Beta hydroxybutyrate	Children: ≥31 mg/dL (3.0 mmol/L) Adults: ≥40 mg/dL (3.8 mmol/L)
Serum ketones	Positive
Anion gap	> 10
Mental status	Drowsy Stupor Coma in moderate to severe DKA

Treatment

Shown below is an algorithm summarizing the treatment of Diabetic ketoacidosis according the American Association of Clinical Endocrinologists (AACE) guidelines.

Step-wise approach to management of diabetic ketoacidosis

DKA treatment protocol according to ADA guidelines

Fluids

Bicarbonate

Insulin

Potassium

Hydration status

pH greater than equal to 6.9

pH less than 6.9

0.1 u/kg/B.WT. as IV bolus

0.14 u/kg/B.WT/hr as continous IV infusion

K < 3.3 mEq/L

K = 3.3 - 5.2 mEq/L

K > 5.2 mEq/L

Severe hypovolemia

Mild dehydration

Cardiogenic shock

0.1 u/kg/B.WT. as IV continous infusion

Hold insulin and give 20-30mEq/L of potassium until K+ > 3.3mEq/L

Give 20-30mEq/L in each liter of IV fluids to maintain serum K 4-5mEq/L

Do not give potassium but check serum potassium every 2 hours

0.9% Nacl (1L/hr) as IV infusion

Check corrected serum sodium

Hemodynamic monitoring and add pressors accordingly

If serum glucose does not fall by 10 % within one hour of therapy then give 0.14 U/Kg as IV bolus and continue previous regimen

High serum Na (>145 mEq/L)

Normal serum Na (135-145 mEq/L)

Low serum Na (< 135 mEq/L)

When serum glucose drops to 200 mg/dl, reduce regular insulin to 0.02-0.05 U/Kg/hour, or give rapid-acting insulin at 0.1 U/kg SC every 2 hours, maintain serum glucose between 150 mg/dl to,200 mg/dl until resolution

0.45% NaCl (250-500 ml per hour depending on hydration status

0.9% NaCl (200-500 ml per hour) depending on hydration status

When serum glucose decreases to 200 mg/dl, switch to 5% dextrose with 0.45% NaCl at 150-250 ml/hour

Do's

• The content in this section is in bullet points.

Don'ts

• The content in this section is in bullet points.

References

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