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 login to view 1 more bullet Abdominal symptoms login to view 1 more bullet Dehydration Fruity breath login to view 1 more bullet polydipsia polyuria Studies Diagnostic testing studies ↑ blood glucose anion gap metabolic acidosis ↑ ketones in serum and urine ↓ bicarbonate ↑ potassium login to view 3 more bullets ↑ free calcium login to view 1 more bullet Differential Hyperosmolar hyperglycemic state distinguishing factors minimal or no serum ketones normal acid-base state DIAGNOSIS Diagnostic criteria blood glucose > 250 mg/dL serum bicarbonate < 18 mmol/L + serum ketones acidosis with pH < 7.3 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 Cerebral edema a feared complication more common in pediatric patients presents with confusion and seizures treat by slowing rate of treatment, mannitol/hypertonic saline, elevate head of the bed, and benzodiazepines