If a heart attack seems possible, your doctor might recommend further evaluation of your heart. Diabetic ketoacidosis is life-threatening. If you develop mild signs and symptoms, contact your doctor immediately.
A medical provider who sees you for possible diabetic ketoacidosis will need answers to these questions as quickly as possible:. Mayo Clinic does not endorse companies or products. Advertising revenue supports our not-for-profit mission.
This content does not have an English version. This content does not have an Arabic version. Diagnosis If your doctor suspects diabetic ketoacidosis, he or she will do a physical exam and order blood tests.
Blood tests Blood tests used in the diagnosis of diabetic ketoacidosis will measure:. Request an Appointment at Mayo Clinic. The goal of treatment is to correct the high blood sugar level with insulin. Another goal is to replace fluids lost through urination, loss of appetite, and vomiting if you have these symptoms. If you have diabetes, it is likely your health care provider told you how to spot the warning signs of DKA.
If you think you have DKA, test for ketones using urine strips. Some glucose meters can also measure blood ketones. If ketones are present, call your provider right away.
DO NOT delay. Follow any instructions you are given. It is likely that you will need to go to the hospital. There, you will receive insulin, fluids, and other treatment for DKA. Then providers will also search for and treat the cause of DKA, such as an infection. Go to the emergency room or call the local emergency number such as if you or a family member with diabetes has any of the following:.
If you have diabetes, learn to recognize the signs and symptoms of DKA. Know when to test for ketones, such as when you are sick. If you use an insulin pump, check often to see that insulin is flowing through the tubing. Make sure the tube is not blocked, kinked or disconnected from the pump. American Diabetes Association. Diabetes Care. PMID: pubmed. Type 1 diabetes. Williams Textbook of Endocrinology.
Mental status can vary from somnolence to lethargy and coma. A detailed evaluation may reveal precipitating factors, especially nonadherence to medical regimens and infection, which are common causes of DKA. Although hyperosmolar hyperglycemic state can be confused with DKA, ketone levels are low or absent in persons with hyperosmolar hyperglycemic state. Other causes of high anion gap metabolic acidosis, such as alcoholic ketoacidosis and lactic acidosis, must be ruled out.
Table 2 provides the differential diagnosis of DKA. Myocardial infarction Starvation ketosis Alcoholic ketoacidosis.
Ethylene glycol intoxication. Lactic acidosis. Methanol intoxication. Paraldehyde ingestion. Salicylate intoxication. Information from references 14 and The diagnosis of DKA Table 3 is based on an elevated serum glucose level greater than mg per dL [ One review indicated that venous and arterial pH are clinically interchangeable in persons who are hemodynamically stable and without respiratory failure.
Although persons with DKA usually have a glucose level greater than mg per dL, a few case reports document DKA in pregnant women who were euglycemic. Table 4 provides formulas to calculate the anion gap, serum osmolality, osmolar gap, and serum sodium correction. Hyperglycemic crisis in adult patients with diabetes. Adapted with permission from Wilson JF. In clinic. Diabetic ketoacidosis. Ann Intern Med. In one study, the urine dipstick test was negative for ketones in six of 18 persons. Ketonemia was defined as a ketone level greater than 0.
Further initial laboratory studies should include measurement of electrolytes, phosphate, blood urea nitrogen, and creatinine; urinalysis; complete blood count with differential; and electrocardiography Table 5. An initial potassium level less than 3. Amylase and lipase levels may be increased in persons with DKA, even in those without associated pancreatitis; however, 10 to 15 percent of persons with DKA do have concomitant pancreatitis. Arterial blood gas measurement is the most widely recommended test for determining pH, but measurement of venous blood gas has gained acceptance.
Assesses effect of potassium status; rules out ischemia or myocardial infarction. Confirms the presence of glucose and ketones, and will help assess for presence of a urinary tract infection.
May be elevated in persons with DKA, even in those without associated pancreatitis. Diagnosis of myocardial infarction should be based on clinical judgment and imaging. Leukocytosis can occur even in the absence of infection; bandemia more accurately predicts infection. One study showed that an elevated band count in persons with DKA had a sensitivity for predicting infection of percent 19 out of 19 cases and a specificity of 80 percent.
An elevated hemoglobin level caused by dehydration may also exist. Elevated hepatic transaminase levels may occur, especially in persons with fatty liver disease. Figure 1 4 , 29 provides the treatment approach for DKA in adults, and Figure 2 24 , 30 provides the treatment approach for DKA in persons younger than 20 years. Both approaches are recommended by the American Diabetes Association. Specific issues for the adult patient are discussed in more detail below.
For persons younger than 20 years, insulin should be administered gradually, and fluid and electrolyte replacement should be done cautiously because of limited data and concern for precipitating cerebral edema. Additional information from reference Hyperglycemic crisis in diabetes. After determining the level of dehydration, intravenous fluid replacement should be started.
In most persons, saline 0. Fluid status, cardiac status, urine output, blood pressure, and electrolyte level should be monitored. As the patient stabilizes, fluids can be lowered to 4 to 14 mL per kg per hour, or to mL per hour. Once the corrected sodium concentration is normal or high greater than mEq per L [ mmol per L] , the solution can be changed to saline 0.
Dextrose is added when the glucose level decreases to mg per dL To further correct hyperglycemia, insulin should be added to intravenous fluids one to two hours after fluids are initiated. An initial bolus of 0. Glucose level should decrease by about 50 to 70 mg per dL 2. Physiologic and clinical outcomes were identical in all three groups. DKA is resolved when the glucose level is less than mg per dL, the pH is greater than 7. Once these levels are achieved and oral fluids are tolerated, the patient can be started on an insulin regimen that includes an intermediate- or long-acting insulin and a short- or rapid-acting insulin.
When intravenous insulin is used, it should remain in place for one to two hours after subcutaneous insulin is initiated. Persons known to have diabetes can be started on their outpatient dose, with adjustments to improve control. Those new to insulin should receive 0. Although potassium is profoundly depleted in persons with DKA, decreased insulin levels, acidosis, and volume depletion cause elevated extracellular concentrations.
Potassium levels should be monitored every two to four hours in the early stages of DKA. Hydration alone will cause potassium to drop because of dilution. Improved renal perfusion will increase excretion. Insulin therapy and correction of acidosis will cause cellular uptake of potassium.
If the potassium level is in the normal range, replacement can start at 10 to 15 mEq potassium per hour.
If the potassium level is between 3. If the potassium level is lower than 3. If the potassium level is greater than 5. When the potassium level is between 3. Clinical trials are lacking to determine which is best, although in the face of phosphate depletion, potassium phosphate is used.
Bicarbonate therapy in persons with DKA is somewhat controversial. Proponents believe that severe acidosis will cause cardiac and neurologic complications. However, studies have not demonstrated improved clinical outcomes with bicarbonate therapy, and treatment has been associated with hypokalemia. In one retrospective quasi-experimental study of 39 persons with DKA and a pH between 6. Current American Diabetes Association guidelines continue to recommend bicarbonate replacement in persons with a pH lower than 6.
This should be repeated every two hours until the patient's pH is 6. Phosphate levels may be normal to elevated on presentation, but decline with treatment as the phosphate enters the intracellular space.
Studies have not shown a benefit from phosphate replacement, and it can be associated with hypocalcemia and hypomagnesemia. However, because phosphate deficiency is linked with muscle fatigue, rhabdomyolysis, hemolysis, respiratory failure, and cardiac arrhythmia, replacement is recommended when the phosphate level falls below 1. This can be achieved by adding 20 to 30 mEq of potassium phosphate to the intravenous fluid. DKA can cause a drop in magnesium, which can result in paresthesia, tremor, muscle spasm, seizures, and cardiac arrhythmia.
It should be replaced if it falls below 1. Cerebral edema is the most severe complication of DKA. It occurs in 0. Other complications of DKA include hypokalemia, hypoglycemia, acute renal failure, and shock. Less common problems can include rhabdomyolysis, 41 thrombosis and stroke, 42 pneumomediastinum, 43 prolonged corrected QT interval, 44 pulmonary edema, 45 and memory loss with decreased cognitive function in children.
Physicians should recognize signs of diabetes in all age groups, and should educate patients and caregivers on how to recognize them as well eTable A. In one study, persons with DKA had symptoms of diabetes for This includes more frequent glucose monitoring; continuing insulin, but at lower doses, during times of decreased food intake; and checking urine ketone levels with a dipstick test if the glucose level is greater than mg per dL Education for physicians on early recognition of diabetes mellitus symptoms for prompt diagnosis A1.
Group visits A2. Referral for diabetes education with certified educator or pharmacist A3, A4. Telecommunication A5. Early contact with clinician. Insulin reduction rather than elimination. Measurement of urine or serum ketone level. Psychological counseling for those who eliminate insulin for body image concerns, and those who have major depression or other psychological illnesses that interfere with proper management. Assess reasons for discontinuation of insulin e. Referral to community resources.
Effectiveness of a prevention program for diabetic ketoacidosis in children. An 8-year study in schools and private practices. Group visits in diabetes care: a systematic review. Diabetes Educ. National standards for diabetes self-management education.
Pharmacist-led group medical appointment model in type 2 diabetes. New direction for enhancing quality in diabetes care: utilizing telecommunications and paraprofessional outreach workers backed by an expert medical team.
Telemed J E Health. A Web-based interprofessional diabetes education course. Am J Pharm Educ. Sick day management in children and adolescents with diabetes. Pediatr Diabetes. Prescription co-pay reduction program for diabetic employees. Popul Health Manag. Nonadherence to medical regimens is often the cause of recurrent DKA.
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