Diabetic Ketoacidosis

(DKA)

Learning Objectives
Identify precipitating factors for the development of DKA
Outline steps needed to obtain accurate diagnosis of
DKA
Implement strategies for the acute management of DKA
Explain methods that can be used to prevent recurrence
of DKA

DKA Progression
Insulin Deficiency

Increased Lipolysis

Increased Ketogenesis

Ketoacidosis

DKA
3

Overall Management Approach

Early
Detection
-Risk factors
-Signs &
symptoms

Diagnosis
-History
-Physical
exam
-Lab tests

Prevention
-Education

Treatment

Regulation of Ketogenesis and Glucose

Metabolism
Ketogenesis

Gluconeogenesis

Glycogenolysis

Glycolysis

Glycogen
Synthesis

Insulin

Glucagon

Cortisol

Growth
Hormone

Catecholamines

From Kreisberg R. Diabetic ketoacidosis. In: Rifkin H, Porte D, eds. Diabetes mellitus: theory and practice, 4th ed. New5York: Elsevier
Science, 1990:591603.

Precipitating Factors
Inadequate insulin treatment
Infection (UTI, pneumonia, sepsis)
Myocardial infarction, stroke
Drugs
Pregnancy

Signs and Symptoms

Polyuria, polydipsia
Enuresis

Fruity breath
Acetone

Dehydration/Volume
Depletion
Tachycardia
Orthostasis
Reduced skin turgor
Dry mucus
membranes

Kussmaul breathing
Mental status changes
Somnolent
Combative
Drunk
Coma

Abdominal pain
Nausea
Vomiting

Initial Evaluation of the Patient with

Suspected DKA
History of DM, hypoglycemic medication doses, and
symptoms
History of DM-related complications
Medications
Social and medical history (including alcohol use)
Vomiting and ability to take fluids by mouth
8

Initial Evaluation of the Patient with

Suspected DKA (contd)
Plasma glucose
Attempt to identify precipitating event (e.g. infection,
omission of insulin, myocardial infarction)
Assess volume status and degree of dehydration
Assess presence of ketonemia and acid-base
disturbance

Laboratory Evaluation of the Patient

with Suspected DKA (contd)
Complete blood count (WBC often high; left shift
suggests infection)
Serum glucose
Serum ketones
Calculate serum osmolality and anion gap
Measure osmolar gap if ingestion of osmotically active
toxins suspected
10

Laboratory Evaluation of the Patient

with Suspected DKA (contd)
Urinalysis and urine culture
Consider blood culture
Consider chest radiograph
Consider measuring HCG
Acid-base assessment
HbA1c
11

Laboratory Values in DKA

DKA
Glucose (mg/dL)

250-600

Sodium (meq/L)

125-135

Potassium (meq/L)

Normal or increased

Magnesium

Normal

Chloride

Normal

Phosphate
Creatinine (mg/dL)

Decreased
Increased

12

Laboratory Values in DKA (contd)

DKA
Serum Osmolality (mOsm/kg)

300-320

Serum -hydroxybutirat acid (mmol/L)

>0.6

Serum Bicarbonate (meq/L)

<15

Arterial pH

6.8-7.3

Arterial PCO2 (mmHg)

20-30

Anion gap (meq/L)

Increased

13

Diagnostic Criteria
Mild
DKA

Moderate
DKA

Severe
DKA

Plasma glucose (mg/dL)

>250

>250

>250

Effective serum osmolality

(mOsm/kg)[*]

Variable

Variable

Variable

Urine or serum ketones

(NP reaction)

Positive

Positive

Positive

Arterial pH

7.25-7.30

7.00-7.24

<7.00

Serum bicarbonate (mEq/L)

15-18

10-15

<10

Anion gap (mEq/L)

>10

>12

>12

Typical mental status

Alert

Drowsy

Stupor or coma

*Effective serum osmolality (mOsm/kg) = 2 [measured serum sodium (mEq/L)] + [serum glucose (mg/dL)/18]. Normal range = 285 5
mOsm/kg. Urea nitrogen is an ineffective osmole (i.e. it diffuses freely across compartments) and is therefore purposely excluded
from this equation.

14 Diabetes
Modified from Kitabchi AE, Umpierrez G, Murphy MB, et al. Management of hyperglycemic crises in patients with diabetes.
Care 2001;24:131153.

Suggested Fluid Replacement

Administer NS as indicated to maintain hemodynamic status, then

follow general guidelines:
NS for first 4 hours
Consider half NS thereafter
Change to D5 half NS when blood glucose 250 mg/dL

May need to adjust type and rate of fluid administration in the elderly
and in patients with congestive heart failure or renal failure.
Hours

Volume
0.5-1 1 L
2 1L
3 500 mL-1 L
4 500 mL-1 L
5 500 mL-1 L

First 5 hours (total) 3.5-5 L

6-12 200-500 mL/hour
NS, normal saline; D5, 5% dextrose in water

15

Average Electrolyte Losses

Sodium

500 mEq

Chloride

350 mEq

Potassium

300-1000 mEq

Calcium

50-100 mmol

Phosphate

50-100 mmol

Magnesium

25-50 mmol

16

Guidelines for Potassium Replacement

Do not administer potassium if serum potassium >5.5 mEq/L
or if patient is anuric
Remember that normal or high serum potassium may mask
total body depletion in setting of acidosis
Use KCI but alternate with KPO4 if there is severe phosphate
depletion and patient is unable to take phosphate by mouth
Add IV potassium to each liter of fluid administered unless
contraindicated
17

Guidelines for Potassium Replacement

Serum K+ (mEq/L)

Additional K+ Required

<3.5

40 mEq/L

3.5-4.5 20 mEq/L
4.5-5.5 10 mEq/L
>5.5 Stop K or dont start infusion

18

Guidelines for Insulin Management

Regular insulin 0.15 U/kg IV (may not be needed)
Start regular insulin infusion 0.1 U/kg/hour or 5 U/hour
Increase insulin by 1 U/hour every 1-2 hours if <10%
decrease in glucose or no improvement in acid-base
status

19

Guidelines for Insulin Management

(contd)
Decrease insulin by 1-2 U/hour (0.05-0.1 U/kg/hour)
when glucose 250 mg/dL and/or progressive
improvement in clinical status with decrease in glucose of
>75 mg/dL/hour
Do not decrease insulin infusion to <1 U/hour

20

Guidelines for Insulin Management

(contd)
Maintain glucose 140-180 mg/dL (hyperglycemia
resolves before acidosis)
If blood glucose decreases to <80 mg/dL, stop insulin
infusion for no more than 1 hour and restart infusion at
lower dose
If blood glucose drops consistently to <100 mg/dL,
change IV fluids to D10

21

Guidelines for Insulin Management

(contd)
Once patient is able to eat, consider change to SC
insulin:
Overlap short-acting insulin SC and continue IV infusion for 1-2
hours
For patients with previous insulin regimen: return to prior dose
For patients with newly diagnosed DM: basal-bolus SC insulin
based on 0.6 U/kg/day

22

Management of DKA: Evaluation

Complete Initial Evaluation
Including (but not limited to):
Medical history and physical
examination
Complete blood count with
differential

Urine for urinalysis and ketones

Cultures as indicated (wound,
blood, urine, etc.)

Adult patient
with DKA

Complete
Initial
Evaluation

K+ Repletion

Chest abdominal x-ray

Fingerstick blood glucose
12-lead ECG
Serum chemistries (electrolytes,
BUN, Cr; serum ketones)

IV Fluids

Bicarbonate?

Concurrently, begin empirical fluid resuscitation with 0.9% NaCl

at 1000 mL/hr.
Consider volume expansions if hypovolemic shock is present.
Continue fluid resuscitation until volume status and
cardiovascular parameters (pulse, BP) have been restored.

Insulin
Therapy

When Serum
Glucose Reaches
200 mg/dL

23

Continuing
Management

Management of DKA: K+ Repletion

Potassium (K+) Repletion
Obtain baseline serum potassium. Obtain 12-lead ECG.
K+ 5.5 mEq/L

Hold K+ therapy

Treat hyperkalemia if ECG

changes present

Recheck K+ in 2 hours

Adult patient
with DKA

K+ < 5.5 mEq/L and adequate urine output

Add K+ to IV fluids (use KCI and/or Kphos)

K+ = 4.5 5.4: add 20 mEq/L IV fluids
K+ = 3.5 4.4: add 30 mEq/L IV fluids
K+ < 3.5
: add 40 mEq/L IV fluids

Complete
Initial
Evaluation

K+ Repletion
Insulin
Therapy
IV Fluids

Follow serum K+ every 2-4 hours until stable: anticipate rapid drop of
serum K+ during therapy, due to dilution and intracellular shifting.

Bicarbonate?

Ensure adequate urine output to avoid over-repletion and hyperkalemia.

Continue K+ repletion until serum K+ is stable between 4-5 mEq/L.
If refractory hypokalemia, ensure concurrent magnesium repletion.

When Serum
Glucose Reaches
200 mg/dL

K+ repletion may need to be continued for several days, as total body

losses may reach up to 500 mEq.
24

Continuing
Management

Management of DKA: IV Fluids

IV Fluids

Adult patient
with DKA

Based on corrected serum sodium.*

If high/normal, use 0.45% NaCl

K+ Repletion

If low/normal, use 0.9% NaCl.

Continue IV fluids at 250-1000 mL/hr depending on
volume status, cardiovascular history, and
cardiovascular status (pulse, BP).

Complete
Initial
Evaluation

IV Fluids

Insulin
Therapy
Bicarbonate?

Children: more susceptible to cerebral edema; go slow

When Serum
Glucose Reaches
200 mg/dL

*Sodium correction: Serum sodium should be corrected for

hyperglycemia. For every 100 mg/dL of glucose elevation above
100 mg/dL, add 1.6 mEq/L to the measured sodium value; this
will yield the corrected serum sodium concentration.
25

Continuing
Management

Management of DKA: Insulin Therapy

Insulin Therapy

Adult patient
with DKA

Complete
Initial
Evaluation

Regular insulin bolus 0.15 U/kg.

K+ Repletion

IV infusion, 0.10 U/kg/hr.

Check serum glucose hourly should fall by 50-80
mg/dL/hr.

IV Fluids

Insulin
Therapy
Bicarbonate?

If serum glucose falling too rapidly, back off on insulin

infusion.
If serum glucose rising or falling too slowly, increase
insulin infusion rate by 50-100%.

When Serum
Glucose Reaches
200 mg/dL

26

Continuing
Management

Management of DKA: Bicarbonate

Therapy
Bicarbonate Therapy

Adult patient
with DKA

Obtain arterial blood gas.

Obtain baseline serum bicarbonate.
pH < 6.9

88 mEq/L
(2 amps)
NaHCO3
over 2 hours

6.9 pH < 7.0

44 mEq/L
(1 amp)
NaHCO3
over 1 hour

pH 7.0

Assess need for

bicarbonate

Complete
Initial
Evaluation

K+ Repletion

IV Fluids

Insulin
Therapy
Bicarbonate?

Repeat arterial blood gas after bicarbonate

administration.
Repeat NaHCO3 therapy until pH 7.0, then discontinue
therapy.

When Serum
Glucose Reaches
200 mg/dL

Follow serum bicarbonate q4h until stable.

27

Continuing
Management

Management of DKA: Glucose

When Serum Glucose Reaches

200 mg/dL
Add dextrose to IV fluids at 150-250 mL/hr and adjust
insulin infusion to maintain serum glucose at 140-200
mg/dL until metabolic control is achieved.

Adult patient
with DKA

K+ Repletion

IV Fluids

Continue until anion gap has closed and acidosis has

resolved.
Begin exhaustive search for precipitant of metabolic
decompensation.

Complete
Initial
Evaluation

Insulin
Therapy
Bicarbonate?

When Serum
Glucose Reaches
200 mg/dL

28

Continuing
Management

Management of DKA: Continuing

Management
Continuing Management:

Adult patient
with DKA

Complete
Initial
Evaluation

Follow and replete serum electrolytes (including divalent

cations) q2-4h until stable.
After resolution of hyperglycemic state, follow blood
glucose q4h and initiate SC insulin regimen.

IV Fluids
Potassium

Insulin
Therapy
Bicarbonate?

Convert IV insulin to SC injections, ensuring adequate

overlap.
Begin clear liquid diet and advance as tolerated.
Encourage resumption of ambulation and activity.
Review and update diabetes education, with special
attention to sick day rules.

When Serum
Glucose Reaches
200 mg/dL
Continuing
Management

29

Summary
DKA is a serious acute complication of hyperglycemia
that requires immediate intervention
Management strategies include insulin therapy (IV), fluid
resuscitation and electrolyte repletion
Following stabilization, a diabetes education, SMBG +/urine ketone monitoring, identification of precipitating
factors is recommended to prevent recurrence

30

Case: Mr. J.
Case details:

58-year-old male
Diagnosed with T1DM years ago
Poorly controlled basal bolus therapy
Admitted for surgical removal of kidney stone
Also has hypertension and COPD

31

Case: Mr. J. (contd)

Examination findings:
Physical examinations were within normal limits
Laboratory examination:

Hb 11.4 g/dL
Leu 5400/uL
Tromb 340.000
Ureum 70 mg/dL
Creatinine 2.4 mg/dL
Others were within normal limits

32

Case: Mr. J. (contd)

After the surgery, complains of progressive
dyspnea
Physical examination:

BP 140/100 mmHg
Respiratory rate 32x/minute
Pulse 108 bpm
BG 301 mg/dL

33

Case Discussion: Mr. J.

Questions:
What are the possible causes of dyspnea in this
patient?
What further examinations would you suggest?
How do you choose to manage this condition?

34

Case Study 2
Current clinical situation:
A 23-year old male found unconscious in the hospital
parking lot
No external signs of trauma, but he is breathing
heavily
Initial hypothesis is alcohol intoxication because his
breath smells like alcohol
He is brought to the emergency room for evaluation

Case Study 2 (Contd)

Past medical history: Patient ID card reveals a
history of T1DM since age 19.
Vital signs:
Height 5 11 (180 cm); weight 175 lbs (79.5 kg);
BMI 24.54 kg/m2
Respiratory rate 32 breaths/minute
ECG normal sinus rhythm; heart rate 105 beats/min
BP: 105/60 mmHg
Temperature 99 F

Case Study 2 (Contd)

Lab results:
Serum sodium 133 mEq/L; potassium 5.4 mEq/L;
chloride 98 mEq/L
BUN 32 mg/dL; serum creatinine 1.3 mg/dL;
serum bicarbonate 9 mEq/L
BG 320 mg/dL; hemoglobin A1C 8.3%
pH 6.9; plasma osmolarity 310 mOsm/L
Ketone blood test positive at 1:32; betahydroxybutyrate 3.1 mmol/L; anion gap 26 mEq/L

Case Study 2 (Contd)

Family history: not available
Social history: not available
Medication history (from ID card): basal
insulin and prandial insulin (dosages
unknown)
Diagnosis: diabetic ketoacidosis

Case Study 2: Discussion

What is the level of severity of this
patients ketoacidosis?
What is your first intervention? Follow-up
interventions while in the hospital?
How much insulin would you administer?
By what route?
What additional tests would you perform?