Diabetic Ketoacidosis (DKA): A Medical Emergency Explained || pharmacyteach

 

Diabetic ketoacidosis (DKA)

 

Introduction:  

Diabetic ketoacidosis (DKA) is a severe, acute complication of diabetes that poses a significant threat to life, marked by hyperglycemia, ketoacidosis, and ketonuria. This condition arises when either absolute or relative insulin deficiency prevents glucose from entering cells for use as metabolic energy, leading the liver to swiftly convert fat into ketones for fuel. The excessive production of ketones results in their accumulation in the bloodstream and urine, causing the blood to become acidic. DKA primarily affects individuals with type 1 diabetes, although it can also occur in certain patients with type 2 diabetes. Laboratory tests for diagnosing DKA include blood glucose tests, serum electrolyte assessments, blood urea nitrogen (BUN) tests, and arterial blood gas (ABG) analyses.

Treatment for DKA involves replenishing lost fluids through intravenous administration; managing hyperglycemia with insulin; correcting electrolyte imbalances, especially potassium depletion; restoring acid-base equilibrium; and addressing any existing infections.

When your cells lack sufficient glucose for energy, your body starts to utilize fat for energy, resulting in the production of ketones. Ketones are substances that the body generates when it metabolizes fat for energy. This process occurs when there is an insufficient amount of insulin to utilize glucose, which is the body's typical energy source. An accumulation of ketones in the bloodstream leads to increased acidity. This serves as an indicator that your diabetes may be poorly managed or that you could be falling ill. Elevated ketone levels can be toxic to the body. If these levels rise excessively, diabetic ketoacidosis (DKA) may occur. While DKA can affect anyone with diabetes, it is uncommon in individuals with type 2 diabetes.

In the absence of sufficient insulin, your liver begins to metabolize body fat for energy. As this process occurs, ketones are released into your bloodstream by the liver.

A significant increase in ketones leads to an acidic condition in your blood (resulting in a low blood pH) and can cause dehydration. This situation constitutes a medical emergency. If left untreated, diabetic ketoacidosis (DKA) can be lethal.

 

What are the symptoms of DKA?

Ø Polyuria (frequent urination)

Ø Polydipsia (excessive thirst)

Ø Abdominal pain

Ø Nausea, vomiting

Ø Fruity-smelling breath (from acetone)

Ø Rapid, deep breathing (Kussmaul respiration)

Ø Confusion or drowsiness

Ø Dehydration

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What are the warning signs of DKA?

DKA usually develops slowly. But when vomiting occurs, this life-threatening condition can develop in a few hours. Early symptoms include the following:

• Thirst or a very dry mouth
• Frequent urination
• High blood glucose (blood sugar) levels
• High levels of ketones in the urine

Then, other symptoms appear:

• Constantly feeling tired
• Dry or flushed skin
• Nausea, vomiting, or abdominal pain. Vomiting can be caused by many illnesses, not just ketoacidosis. If vomiting continues for more than two hours, contact your health care provider.
• Difficulty breathing
• Fruity odor on breath
• A hard time paying attention, or confusion 

How long does it take for DKA to develop?

The onset of diabetic ketoacidosis (DKA) can vary, but it typically develops rapidly within 24 hours. In some cases, especially with type 1 diabetes, it can develop in less than 12 hours, and rarely even faster in children or during acute illness.

Context	Time to Onset
Missed insulin (type 1 diabetes)	6–24 hours
Infection or illness	12–48 hours
Undiagnosed new-onset diabetes	Days to weeks (gradual, but worsens rapidly once insulin is too low)
SGLT2 inhibitor use (type 2)	May be delayed and present as euglycemic DKA

 

Fast-Onset Triggers

·         Total insulin omission

·         Sepsis or severe infection

·         MI (heart attack)

·         Pancreatitis

·         Substance abuse (e.g., cocaine)

Certain conditions or situations can contribute to developing DKA because they cause your body to release certain hormones (like cortisol and adrenaline) that lead to insulin resistance. This means you need more insulin than usual.

How do you check for ketone?

You can identify the presence of ketones with a basic urine test that employs a test strip, which is similar to a blood testing strip. It is important to seek guidance from your healthcare provider on when and how to conduct ketone tests. Many specialists suggest testing your urine for ketones when your blood glucose readings are above 240 mg/dl.

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If you are unwell (for instance, suffering from a cold or the flu), it is recommended to check for ketones every four to six hours. Furthermore, check every four to six hours if your blood glucose is greater than 240 mg/dl.Also, check for ketones when you have any symptoms of DKA.

Key features:

Parameter	Abnormal Finding
Blood glucose	>250 mg/dL
Ketones	Positive in blood and urine
pH	<7.3 (acidic)
Bicarbonate	<18 mEq/L
Anion gap	Elevated (>12)
Serum osmolality	Usually normal or slightly increased

 

What tests are used to diagnose DKA?

In the hospital, healthcare providers may use the following tests to diagnose DKA:

• Blood glucose test.
• Ketone testing (through a urine or blood test).
• Arterial blood gas (ABG).
• Basic metabolic panel (BMP).
• Blood pressure measurement.
• Osmolality blood test.

Management and Treatment

Hospital treatment of DKA

Treatment of Diabetic Ketoacidosis (DKA) is a medical emergency that requires hospitalization, often in an intensive care setting. The goals are to:

1.     Restore fluid volume

2.     Correct electrolyte imbalances

3.     Reverse ketosis with insulin

4.     Identify and treat the underlying cause

Here is a detailed step-by-step breakdown of DKA treatment:

 1. Initial Assessment

·         Vital signs: HR, BP, RR, temperature, O2 saturation

·         Mental status

·         Labs: Blood glucose, ketones, ABG, serum electrolytes, BUN/Cr, osmolality, CBC, urinalysis

·         EKG: To check for potassium abnormalities

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 2. Fluid Replacement (Volume Resuscitation)

Purpose: Correct dehydration, improve perfusion, and reduce blood glucose

 

Timeframe	Type of Fluid
First 1–2 hours	0.9% NaCl (normal saline) at 15–20 mL/kg/hr
After stabilization	Switch to 0.45% NaCl if serum sodium is normal or high
When glucose < 200 mg/dL	Add 5% dextrose (D5½NS) to prevent hypoglycemia and allow continued insulin

 

3. Insulin Therapy

Purpose: Suppress ketone production and lower blood glucose

·         Initial bolus (optional): 0.1 units/kg IV regular insulin

·         Continuous infusion: 0.1 units/kg/hour IV

Goal:

·         Decrease glucose by 50–70 mg/dL per hour

·         Continue insulin even if glucose normalizes—must stop ketone production!

When glucose < 200 mg/dL:

·         Reduce insulin rate (0.02–0.05 units/kg/hr)

·         Add D5 to fluids

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 4. Electrolyte Management

 Potassium (K⁺) is critical!

Even if serum K⁺ is normal or high, total body K⁺ is low due to losses in urine and vomiting.

Serum K⁺	Action
> 5.2 mEq/L	Hold K⁺, monitor every 2 hours
3.3–5.2 mEq/L	Add 20–30 mEq K⁺ per liter of IV fluid
< 3.3 mEq/L	Hold insulin, give K⁺ until > 3.3

Other electrolytes:

·         Monitor phosphate and magnesium

·         Replace if symptomatic or very low

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 5. Monitor and Adjust

·         Blood glucose hourly

·         Serum electrolytes, BUN/Cr, venous pH, anion gap every 2–4 hours

·         Adjust fluids, insulin, and electrolytes accordingly

 

 6. Treat the Underlying Cause

Common triggers:

·         Infection → blood/urine cultures, start antibiotics

·         Missed insulin → assess psychosocial factors

·         MI, pancreatitis, stroke → appropriate workup

 

 7. Criteria for Resolution of DKA

·         Blood glucose < 200 mg/dL AND

·         Serum bicarbonate ≥ 15 mEq/L

·         pH > 7.3

·         Anion gap closed (<12)

Once resolved:

·         Transition to subcutaneous insulin

·         Overlap IV and SC insulin for at least 1–2 hours to avoid relapse

 

 Summary Flow

1.     Fluids → stabilize circulation

2.     Insulin → stop ketogenesis

3.     Potassium → prevent arrhythmia

4.     Treat trigger → stop recurrence

5.     Careful monitoring → guide ongoing therapy