Diabetic ketoacidosis

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In medicine, diabetic ketoacidosis (DKA) is a type of metabolic acidosis that is a "life-threatening complication of diabetes mellitus, primarily of Type 1 Diabetes Mellitus with severe insulin deficiency and hyperglycemia. It is characterized by excessive lipolysis, oxidation of fatty acids, production of ketone bodies, a sweet smell to the breath (ketosis;) dehydration; and depressed consciousness leading to coma.[1] can also occur with Diabetes mellitus type 2[2]

DKA is often secondary to infection or other comorbidity, which must be diagnosed and treated.[3][4]

Diagnosis

Criteria from the American Diabetic Association state:

  • Serum glucose ≥ 250 mg/dL
  • Serum anion gap > 10 mEq/L
  • Bicarbonate ≤ 18 mEq/L
  • Serum pH ≤ 7.30
  • Presence of ketosis

Venous blood gas analysis may be used in place of arterial blood gas analysis and serum chemistry.[5]

The blood glucose is above 250 mg/dl in over 90% of patients.[6][7]

Urine test sticks measure acetoacetate and not 3-hydroxybutyrate (β-hydroxybutyrate) although 3-hydroxybutyrate is the predominant ketone. Acetoacetate may not be elevated until later.

The anion gap and serum osmolality must be measured.

Treatment

Treatment begins with fluid replacement; insulin is not started immediately. As DKA is treated, DKA converts from a high anion gap metabolic acidosis to a normal anion gap metabolic acidosis due to "excretion of ketone anions in the urine"[8], especially if excreted with sodium or potassium cations.

DKA is resolved when:[3]

  • glucose level less than 11.1 mmol/L (200 mg/dL)
    • two of
    • serum bicarbonate level ≥ 15 mmol/L
    • venous pH greater than 7.3
    • anion gap < 12

When resolved and the patient is adequately eating, the patient should resume their usual insulin, or if the patient is a new diabetic, they should take a total of 0.5 to 0.8 U/kg per day.[3]

Hospitalization

Criteria for hospitalization, according to the American Diabetic Association, are:[9]

  • Plasma glucose >250 mg/dl (>13.9 mmol/l) with
  1. arterial pH <7.30 and
  2. serum bicarbonate level <15 mEq/l
  3. moderate ketonuria and/or ketonemia

References

  1. Anonymous (2022), Diabetic ketoacidosis (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. Umpierrez GE, Smiley D, Kitabchi AE (2006). "Narrative review: ketosis-prone type 2 diabetes mellitus.". Ann Intern Med 144 (5): 350-7. PMID 16520476.
  3. 3.0 3.1 3.2 Wilson JF (2010). "In clinic. Diabetic ketoacidosis.". Ann Intern Med 152 (1): ITC1. DOI:10.1059/0003-4819-152-1-201001050-01001. PMID 20048266. Research Blogging. Cite error: Invalid <ref> tag; name "pmid20048266" defined multiple times with different content Cite error: Invalid <ref> tag; name "pmid20048266" defined multiple times with different content
  4. Rucker DW (February 12, 2008), "Diabetic ketoacidosis", eMedicine
  5. Menchine M, Probst MA, Agy C, Bach D, Arora S (2011). "Diagnostic accuracy of venous blood gas electrolytes for identifying diabetic ketoacidosis in the emergency department.". Acad Emerg Med 18 (10): 1105-8. DOI:10.1111/j.1553-2712.2011.01158.x. PMID 21951652. Research Blogging.
  6. Lebovitz HE (1995). "Diabetic ketoacidosis.". Lancet 345 (8952): 767-72. PMID 7891491.
  7. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN (2009). "Hyperglycemic crises in adult patients with diabetes.". Diabetes Care 32 (7): 1335-43. DOI:10.2337/dc09-9032. PMID 19564476. PMC PMC2699725. Research Blogging.
  8. Oh MS, Carroll HJ, Goldstein DA, Fein IA (December 1978). "Hyperchloremic acidosis during the recovery phase of diabetic ketosis". Ann. Intern. Med. 89 (6): 925–7. PMID 102229. [e]
  9. American Diabetes Association (2004). "Hospital admission guidelines for diabetes.". Diabetes Care 27 Suppl 1: S103. PMID 14693939. [e]