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Diabetic ketoacidosis

What's new

Updated 2023 ADA guidelines for the management of diabetic ketoacidosis.

Background

Overview

Definition
DKA is an acute metabolic complication of diabetes characterized by a triad of hyperglycemia, ketosis, and acidemia.
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Pathophysiology
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.
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Disease course
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.
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Prognosis and risk of recurrence
The overall mortality rate of DKA is around 10%.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of diabetic ketoacidosis are prepared by our editorial team based on guidelines from the American Diabetes Association (ADA 2024), 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 (DC 2018), the British Thoracic ...
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Diagnostic investigations

Urine ketones: as per DC 2018 guidelines, do not rule out DKA on the basis of negative urine ketones.
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  • Capillary beta-hydroxybutyrate

  • Blood gas analysis

  • Evaluation of patients on SGLT-2 inhibitors

Medical management

IV fluid resuscitation: as per DC 2018 guidelines, 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.
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  • Insulin infusion

  • Insulin infusion (FICS)

  • Dextrose infusion

  • Potassium replacement

  • Sodium bicarbonate

  • Maintenance fluids

Inpatient care

Inpatient monitoring: as per SFMU/SRLF 2019 guidelines, consider obtaining close monitoring in patients with DKA, ideally in an ICU setting.
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  • Glucose monitoring

Patient education

Counseling on SGLT-2 inhibitors use: as per UKKA 2021 guidelines, initiate SGLT-2 inhibitors with caution in patients with T2DM at greater risk of DKA, and after discussion with the diabetes team.
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Preventative measures

Withholding SGLT-2 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.
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