Updated: 6/19/2019

Diabetic Ketoacidosis (DKA)

Topic
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Evidence
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Snapshot
  • A 13-year-old girl with a past medical history of anxiety is brought to the emergency room for nausea, vomiting, and abdominal pain. She is also reports increased urinary frequency. On physical exam, she is lethargic and markedly dehydrated with dry mucous membranes and sunken eyes. Her abdominal exam is benign. Laboratory results show increased serum glucose of 400 mg/dL and hyperkalemia of 4.9 mmol/L. A urinalysis is positive for ketones. She is given fluids and admitted to the intensive care unit for close monitoring and administration of an insulin drip.  
Introduction
  • Clinical definition
    • diabetic ketoacidosis (DKA) is a complication of hyperglycemia associated with type 1 diabetes, characterized by
      • metabolic acidosis
      • gastrointestinal symptoms
      • altered mental status
      • serum ketones
  • Epidemiology
    • demographics
      • often occur in patients with newly diagnosed diabetes
    • etiology          
      • insulin noncompliance
      • acute medical illness
        • infection
        • stroke
        • myocardial infarction
      • new-onset diabetes
  • Pathogenesis
    • ↑ insulin requirements result in excess fat breakdown and ketogenesis, resulting in ↑ ketone bodies like β-hydroxybutyrate
Presentation
  • Symptoms
    • acute-onset
    • DKA can cause Death Fast
      • Delirium/altered mental status/psychosis
      • Kussmaul respirations
        • rapid and deep breathing
      • Abdominal symptoms
        • pain, nausea, and vomiting
      • Dehydration
      • Fruity breath
        • caused by acetones
    • polydipsia
    • polyuria
Studies
  • Diagnostic testing
    • studies
      • ↑ blood glucose
      • anion gap metabolic acidosis
      • ↑ ketones in serum and urine
      • ↓ bicarbonate
      • ↑ potassium  
        • however, while labs show hyperkalemia, overall potassium levels may actually be low due to
          • transcellular shift with acidosis
          • loss of potassium through urine due to osmotic diuresis
      • ↑ free calcium
        • excess hydrogen displaces calcium from albumin
  • Diagnostic criteria
    • blood glucose > 250 mg/dL
    • serum bicarbonate < 18 mmol/L
    • + serum ketones
    • acidosis with pH < 7.3
Differential
  • Hyperosmolar hyperglycemic state
    • distinguishing factors
      • minimal or no serum ketones
      • normal acid-base state
Treatment
  • Management approach
    • patients with DKA should be monitored in the intensive care unit
  • First-line
    • intravenous fluid resuscitation
    • intravenous insulin
      • sometimes will administer with glucose to prevent hypoglycemia
      • do not start if potassium is low
      • administer until anion gap normalizes  
    • replete potassium
      • if a patient is hypokalemic replete before giving insulin 
Complications
  • Mucormycosis
    • Rhizopus infection
  • Renal failure
  • Cardiac arrhythmias
 

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Questions (10)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.EC.4829) A 20-year-old female with type I diabetes mellitus presents to the emergency department with altered mental status. Her friend said that she has been out late either studying for upcoming tests or attending prayer group meetings. As far as the friend can recollect, the patient appeared to be in her usual state of health until only two days ago, when she was prescribed trimethoprim-sulfamethoxazole for a urinary tract infection. The patient complained that the medication was making her feel nauseous and bloated. The patient also relies on glargine and lispro for glycemic control. Her temperature is 100.5°F (38.1°C), blood pressure is 95/55 mmHg, pulse is 130/min, and respirations are 30/min. Her pupils are equal and reactive to light bilaterally. The remainder of the physical exam is unremarkable. Her basic metabolic panel is displayed below:

Serum:
Na+: 116 mEq/L
Cl-: 90 mEq/L
K+: 5.0 mEq/L
HCO3-: 2 mEq/L
BUN: 50 mg/dL
Glucose: 1,200 mg/dL
Creatinine: 1.5 mg/dL

Which of the following is true regarding this patient's presentation? Review Topic

QID: 109465
1

Hyponatremia is independently associated with a poor prognosis

6%

(3/50)

2

Hyperkalemia is independent of the patient's total body potassium stores

52%

(26/50)

3

Hyperglycemia to this magnitude supports hyperglycemic hyperosmolar nonketotic syndrome

24%

(12/50)

4

Azotemia independently contributes to the patient's encephalopathy

0%

(0/50)

5

Hypochloremia to this magnitude supports a pure anion-gap metabolic acidosis

16%

(8/50)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(M2.EC.4752) A 19-year-old man with unknown medical history is found down on a subway platform and is brought to the hospital by ambulance. He experiences two episodes of emesis en route. In the emergency department, he appears confused and is complaining of abdominal pain. His temperature is 37.0° C (98.6° F), pulse is 94/min, blood pressure is 110/80 mmHg, respirations are 24/min, oxygen saturation is 99% on room air. His mucus membranes are dry and he is taking rapid, deep breathes. Laboratory work is presented below:

Serum:
Na+: 130 mEq/L
K+: 4.3 mEq/L
Cl-: 102 mEq/L
HCO3-: 12 mEq/L
BUN: 15 mg/dL
Glucose: 362 mg/dL
Creatinine: 1.2 mg/dL
Urine ketones: Positive


The patient is given a bolus of isotonic saline and started on intravenous insulin drip. Which of the following is the most appropriate next step in management? Review Topic

QID: 108739
1

Subcutaneous insulin glargine

5%

(1/22)

2

Intravenous isotonic saline

9%

(2/22)

3

Intravenous sodium bicarbonate

5%

(1/22)

4

Intravenous potassium chloride

77%

(17/22)

5

Intravenous 5% dextrose and 1/2 isotonic saline

5%

(1/22)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(M2.EC.27) A 12-year-old female presents to the emergency room difficult to arouse and occasionally vomiting. On physical exam, her oral mucosa looks dry, her breath has a fruity odor, and her breathing is slow, deep and labored. What is the most likely primary metabolic disturbance? Review Topic

QID: 102968
1

Anion gap metabolic acidosis

0%

(0/0)

2

Non-anion gap metabolic acidosis

0%

(0/0)

3

Metabolic alkalosis

0%

(0/0)

4

Respiratory alkalosis

0%

(0/0)

5

Respiratory acidosis

0%

(0/0)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(M2.EC.70) A 23-year-old female is found by her roommate in her dormitory. The patient has a history of Type 1 Diabetes Mellitus and was binge drinking the night prior with friends at a local bar. The patient is brought to the emergency department, where vital signs are as follow: T 97.3 F, HR 119 bpm, BP 110/68 mmHg, RR 24, SpO2 100% on RA. On physical exam, the patient is clammy to touch, mucous membranes are tacky, and she is generally drowsy and disoriented. Finger stick glucose is 342 mg/dL; additional lab work reveals: Na: 146 K: 5.6 Cl: 99 HCO3: 12 BUN: 18 Cr: 0.74. Arterial Blood Gas reveals: pH 7.26, PCO2 21, PO2 102. Which of the following statements is correct regarding this patient's electrolyte and acid/base status? Review Topic

QID: 104395
1

The patient has a primary respiratory alkalosis with a compensatory metabolic acidosis

0%

(0/5)

2

The patient has a metabolic acidosis with hyperkalemia from increased total body potassium

60%

(3/5)

3

The patient has an anion gap metabolic acidosis as well as a respiratory acidosis

0%

(0/5)

4

The patient has an anion gap metabolic acidosis with decreased total body potassium

40%

(2/5)

5

The patient has a non-anion gap metabolic acidosis with decreased total body sodium

0%

(0/5)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(M2.EC.14) A 22-year-old woman with a history of type I diabetes mellitus presents to the emergency department with nausea, vomiting, and drowsiness for the past day. Her temperature is 98.3°F (36.8°C), blood pressure is 114/74 mmHg, pulse is 120/min, respirations are 27/min, and oxygen saturation is 100% on room air. Physical exam is notable for a confused and lethargic young woman. Initial laboratory values are notable for the findings below.

Serum:
Na+: 139 mEq/L
Cl-: 100 mEq/L
K+: 2.9 mEq/L
HCO3-: 9 mEq/L
BUN: 20 mg/dL
Glucose: 599 mg/dL
Creatinine: 1.1 mg/dL
Ca2+: 10.2 mg/dL
AST: 12 U/L
ALT: 10 U/L

An initial ECG is notable for sinus tachycardia. Which of the following is the best initial step in management for this patient? Review Topic

QID: 104339
1

Insulin and potassium

0%

(0/0)

2

Normal saline and insulin

0%

(0/0)

3

Normal saline and potassium

0%

(0/0)

4

Normal saline, insulin, and potassium

0%

(0/0)

5

Normal saline, insulin, potassium, and sodium bicarbonate

0%

(0/0)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
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