Guideline sources The following summarized guidelines for the evaluation and management of diabetic ketoacidosis (DKA) are prepared by our editorial team based on guidelines from the American Diabetes Association (ADA 2023), the United Kingdom Kidney Association (UKKA 2021), the Kidney Disease: Improving Global Outcomes Foundation (KDIGO 2020), the French Society of Emergency Medicine (SFMU/SRLF 2019), the Diabetes Canada Guidelines (Diabetes Canada 2018), the British Thoracic Society (BTS 2017), and the Guidelines and Audit Implementation Network (GAIN 2014). 1 2 3 4 5 6 7 8 8 8 9 Definition DKA is an acute metabolic complication of diabetes characterized by a triad of hyperglycemia, ketosis, and acidemia. 8 Epidemiology DKA is caused by inadequate insulin therapy in hospital, new diagnosis of T1DM mellitus, poor concordance with insulin treatment, infection (commonly chest, urinary tract, skin), and acute coronary/vascular event. 9 Disease course https://web.pathway.md/diseases/recwQ3Cgp3qeCQ7od 1/6 6/29/23, 10:13 PM Diabetic ketoacidosis Pathway Clinical manifestations include nausea, vomiting, abdominal pain, weakness, polydipsia, polyuria, dehydration, fruity odor of breath, rapid shallow Kussmaul breathing, hypotension, and altered sensorium. Delay in hospitalization, acidosis severity, and peripheral vascular insufficiency are associated with increased mortality. 8 Prognosis and risk of recurrence The overall mortality rate of DKA is around 10%. 8 Calculator Diabetic Ketoacidosis Mortality Guidelines 1. Diagnostic investigations Urine ketones: do not rule out DKA on the basis of negative urine ketones. D Capillary beta-hydroxybutyrate: Consider obtaining point-of-care capillary -hydroxybutyrate testing in the hospital or outpatient setting to screen for DKA in patients with T1DM and capillary blood glucose > 14 mmol/L. C Obtain further testing for DKA in patients with a -hydroxybutyrate > 1.5 mmol/L. B Blood gas analysis: obtain blood gas analysis in patients with breathlessness thought to be at risk of DKA. B Evaluation of patients on SGLT2 inhibitors: assess patients treated with SGLT-2 inhibitors with symptoms of DKA for this condition, even if blood glucose is not elevated. B 2. Medical management IV fluid resuscitation: administer 0.9% sodium chloride (500 mL/hour IV for 4 hours, then 250 mL/hour for 4 hours) in order to correct hypovolemia in adult patients with DKA. B Show 2 more Insulin infusion: As per ADA 2023 guidelines, administer SC or IV insulin to rapidly correct the hyperglycemia and the metabolic derangement in patients with ketosis/ketoacidosis. Re-initiate metformin once acidosis is resolved while continuing SC insulin therapy. A As per Diabetes Canada 2018 guidelines: Administer continuous intravenous infusion of short-acting insulin at a rate of 0.10 units/kg/hour in patients with DKA. B https://web.pathway.md/diseases/recwQ3Cgp3qeCQ7od 2/6 6/29/23, 10:13 PM Diabetic ketoacidosis Pathway Continue IV insulin infusion until resolution of ketosis, B as measured by the normalization of the plasma anion gap. B Insulin infusion (FICS): consider administering insulin IV rather than SC in patients with DKA. C Show 3 more Dextrose infusion: administer IV dextrose once the plasma glucose concentration falls to 14.0 mmol/L, in order to avoid hypoglycemia. B Potassium replacement: Add potassium to IV fluids immediately in patients with presenting with normal potassium levels or hypokalemia. Add potassium in patients initially presenting with hyperkalemia once serum potassium falls to < 5-5.5 mmol/L and the patient is diuresing. Consider administering potassium phosphate with the aim to prevent rhabdomyolysis in patients with DKA and severe hypophosphatemia. Sodium bicarbonate: avoid administering sodium bicarbonate in patients with DKA. D Maintenance fluids: switch from 0.9% sodium chloride to 0.45% sodium chloride (with potassium chloride) as maintenance fluid therapy once the initial fluid deficit has been corrected. Maintain IV fluids at higher osmolality (may need to maintain on normal saline) if plasma osmolality is falling more rapidly than 3 mmol/kg/hour and/or the corrected plasma sodium is reduced. 3. Inpatient care Inpatient monitoring: consider obtaining close monitoring in patients with DKA, ideally in an ICU setting. E Glucose monitoring: recognize that capillary glucose testing with a glucometer may not provide an accurate or reliable measure of blood glucose in DKA. Obtain a venous blood sample for analysis. E 4. Patient education Counseling on SGLT2 inhibitors use: initiate SGLT-2 inhibitors with caution in patients with T2DM at greater risk of DKA, and after discussion with the diabetes team. B Show 6 more 5. Preventative measures Withholding SGLT2 inhibitors: As per UKKA 2021 guidelines, consider withholding SGLT-2 inhibitors for the duration of the fasting period in patients choosing to intermittently fast (such as for Ramadan), particularly in the elderly, patients on diuretics, or with CKD. C As per KDIGO 2020 guidelines, consider withholding SGLT-2 inhibitors during times of prolonged fasting, surgery, or critical medical illness (when patients may be at greater risk for https://web.pathway.md/diseases/recwQ3Cgp3qeCQ7od 3/6 6/29/23, 10:13 PM Diabetic ketoacidosis Pathway ketosis). C Clinical findings Symptoms Past medical history Abdominal pain Diabetes mellitus Confusion Poorly controlled diabetes Fainting Social history Fatigue Increased appetite Alcohol consumption Nausea Neurological exam Polydipsia Polyuria Altered mental status Shortness of breath Coma Somnolence Lethargy Thirst Visual disturbances Integument exam Vomiting Dehydration Weight loss Medication history Corticosteroids SGLT-2 inhibitors Vital signs Hypotension Tachycardia Tachypnea Respiratory exam Fruity breath odor Lab findings Metabolic acidosis blood glucose serum HbA1c serum anion gap serum ketones serum osmolal gap serum phosphate serum potassium serum sodium serum -hydroxybutyrate urine glucose urine ketones https://web.pathway.md/diseases/recwQ3Cgp3qeCQ7od 4/6 6/29/23, 10:13 PM Diabetic ketoacidosis Pathway serum bicarbonate serum magnesium serum pH serum potassium Likelihood Ratios Pertinent positives The following findings increase the probability of diabetic ketoacidosis in diabetic patients with hyperglycemia. 9 10 Finding LR+ Value Decreased serum bicarbonate 84 Increased serum anion gap (> 16 meq/L) 6.13 Increased serum -hydroxybutyrate (> 1.5 mmol/L) 4.67 Increased urine ketones 1.51 Pertinent negatives The following findings decrease the probability of diabetic ketoacidosis in diabetic patients with hyperglycemia. 9 10 Finding LR- Value serum -hydroxybutyrate not increased ( 1.5 mmol/L) 0.03 urine ketones not increased 0.06 serum anion gap not increased ( 16 meq/L) 0.09 serum bicarbonate not decreased 0.16 References 1. Jeannette Goguen, MD, MEd et al. Hyperglycemic Emergencies in Adults. Can J Diabetes. 2018 Apr;42 Suppl 1 S109 S114. Open 2. McVeigh G, Maxwell P, O'Donell S et al. Guidelines for the Treatment of Hyperkalaemia in Adults. GAIN Sub-Group on the Treatment of Hyperkalaemia in Adults. Open 3. Boris Jung, Mika l Martinez, Yann-Erick Claessens et al. Diagnosis and management of metabolic acidosis: guidelines from a French expert panel. Ann Intensive Care. 2019 Aug 15;9 1 92. Open 4. William G. Herrington, Andrew H. Frankel, Alexa Wonnacott et al. UK Kidney Association Clinical Practice Guideline: Sodium-Glucose Co-transporter-2 SGLT 2 Inhibition in Adults with Kidney Disease. UKKA. 2021 Oct. Open 5. Kidney Disease: Improving Global Outcomes KDIGO Diabetes Work Group. KDIGO 2020 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease. Kidney Int. 2020 Oct;98 4S S1 S115. Open https://web.pathway.md/diseases/recwQ3Cgp3qeCQ7od 5/6 6/29/23, 10:13 PM Diabetic ketoacidosis Pathway 6. Steven E. Kahn, Cheryl A.M. Anderson, John B. Buse et al. Standards of Care in Diabetes 2023. Diabetes Care. 2023 Jan;46 Supplement_1 S1 S291. Open 7. O'Driscoll BR, Howard LS, Earis J et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017 Jun;72 Suppl 1):ii1-ii90. Open 8. Pankaj Seth, Harpreet Kaur, Maneet Kaur. Clinical Profile of Diabetic Ketoacidosis: A Prospective Study in a Tertiary Care Hospital. 2015 Jun;9 6 OC01 4.2015 Jun;9 6 OC01 4. Open 9. Kate Evans. Diabetic ketoacidosis: update on management. 2019 Sep;19 5 396 398.2019 Sep;19 5 396 398. Open 10. Schwab TM, Hendey GW, Soliz TC. Screening for ketonemia in patients with diabetes. Ann Emerg Med. 1999 Sep;34 3 342 6. Open 11. Arora S, Henderson S, Long T et al. Diagnostic Accuracy of Point-of-Care Testing for Diabetic Ketoacidosis at Emergency-Department Triage. Diabetes Care. 2011 Apr; 34 4 852 854. Open 12. Pankaj Seth, Harpreet Kaur, and Maneet Kaur. Clinical Profile of Diabetic Ketoacidosis: A Prospective Study in a Tertiary Care Hospital. J Clin Diagn Res. 2015 Jun; 9 6 OC01 OC04. Open 13. Kate Evans. Diabetic ketoacidosis: update on management. Clin Med Lond). 2019 Sep; 19 5 396 398. Open 14. Stamatis P Efstathiou, Aphrodite G Tsiakou, Dimitrios I Tsioulos et al. A mortality prediction model in diabetic ketoacidosis. Clin Endocrinol (Oxf). 2002 Nov;57 5 595 601. Open https://web.pathway.md/diseases/recwQ3Cgp3qeCQ7od 6/6