Diabetic Ketoacidosis (DKA)

Diagnostic Criteria ₍₁₎

• Glucose > 250 (though “euglycemic ketoacidosis” as a side effect of SGLT-2 inhibitors is emerging in case reports)
• pH < 7.30
• Bicarbonate ≤ 18
• Anion Gap > 12
• Ketones present in urine
• Elevated serum ketones (beta-hydroxybutyrate)

3 “pillars” of DKA

• Hypovolemia
  • Secondary to osmotic diuresis from hyperglycemia
  • This issue is the most likely to be lethal to the patient

• Hypokalemia
  • Potassium levels may appear normal (in acidemia, cell membrane channels shift H⁺ inside the cell in exchange for shifting K⁺ outside the cell), but total body levels are decreased secondary to osmotic diuresis

• Acidemia
  • Secondary to ketoacid production as a result of lipolysis (a lack of insulin prevents cells from using glucose as an energy source, so they turn to lipids)

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

1. Trachtenbarg, David E. Diabetic Ketoacidosis. 1 May 2005, http://www.aafp.org/afp/2005/0501/p1705.html.