Diabetic Ketoacidosis (DKA)

Diagnostic Criteria ₍₁₎

Glucose > 250 (though “euglycemic ketoacidosis” is possible in patients who are taking SGLT-2 inhibitors, have received insulin prior to presentation, those with poor oral intake, and pregnant patients)
Arterial pH < 7.30
Bicarbonate ≤ 18
Anion Gap > 10
Ketones present in urine
Elevated serum ketones (beta-hydroxybutyrate)

3 “pillars” of DKA

Hypovolemia
- Secondary to hyperglycemia-induced osmotic diuresis
- This is the “pillar” most likely to be lethal to the patient

Acidemia
- Ketoacid production secondary to lipolysis (a lack of insulin prevents cells from using glucose as an energy source, so lipids are utilized instead)
- Possible lactic acidosis secondary to hypovolemia/hypoperfusion
Hypokalemia
- Potassium levels may appear normal (with acidemia, cell membrane channels shift H⁺ inside the cell in exchange for shifting K⁺ outside the cell), but total body levels are generally decreased secondary to osmotic diuresis

Management

Remember to investigate for an underlying etiology of the DKA:

Infection/Inflammation
Ischemia/Infarction (MI, CVA, AMI, PE)
Insulin deficiency (insulin requirements higher than prescription, non-compliance)
Pregnancy

References

Kitabchi, A. E., Umpierrez, G. E., Miles, J. M., & Fisher, J. N. (2009, July). Hyperglycemic crises in adult patients with diabetes. Diabetes care. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2699725/