Diabetic Ketoacidosis (DKA)

Will Bassett, Matthew Gonzalez, Dena Kofahi

Background

  • Classically in type 1 diabetes but can also occur in type 2 diabetes.
  • Definition: ↑ blood glucose (typically >350) w/ high anion gap and ketones in blood/urine.
  • If glucose is significantly elevated but little to no ketones/anion gap present, you likely have HHS, which is typically associated with ↑ serum osm and BG > 600.
  • DKA and HHS can occur concurrently.

Evaluation

  • Labs: BMP with anion gap (AG), CBC, phos, blood gas, serum osms, UA, consider beta-hydroxybutyrate.
  • Workup aimed at discovering the underlying cause (The "I’s"):
    • Infection/ Inflammation: CBC, CXR, UA/UCx, LFTs; consider BCx, lipase (pancreatitis). Note: Leukocytosis will be present in DKA, even if infection isn’t the precipitating factor.
    • Ischemia (MI, CVA, mesenteric ischemia): EKG, Troponin, CT(A) if clinical suspicion.
    • Intoxication - Ethanol (can cause ketosis with or without acidosis), cocaine, MDMA.
    • Impregnation - Beta HCG if appropriate.
    • Insulin-openia/Iatrogenic: steroids, SGLT2 inhibitors, other meds, insulin delivery failure (pump failure, insulin degraded by heat, etc.)
  • Remember to correct sodium for hyperglycemia (Na + 2.4mEq * (BG-100).

Management

  • Initial monitoring: q2-4h BMPs (monitor K closely), q1h BG finger stick.
    • Can space less frequently once gap is closed x 2 and pt off insulin infusion.
  • Ensure IV access
  • Start IV fluids, insulin, and potassium as below
    • Start insulin gtt
    • Start subcutaneous long-acting insulin as soon as insulin drip/IV insulin is started (If delayed start at least 2h before starting insulin drip).
      • Either start home long-acting (dose reduce as needed) or if insulin naïve, Lantus 0.2-0.3u/kg/day.
    • Lactated ringers’ preferred fluid if no contraindication.
    • Dextrose should be added when BG <200 (or clear liquid diet).
    • Turn off insulin drip when anion gap is closed/bicarb has normalized on two consecutive BMPs.
  • Consult endocrinology early.
  • Management algorithm on next page (Diabetes Care. 2009 Jul; 32(7): 1335–1343).
  • Note: pts are usually deficient in total body potassium even if serum potassium is high.

Additional Information

  • Pts on insulin drip can be admitted to stepdown (8MCE) with order set.
  • Pts can be admitted to stepdown on a subcutaneous insulin protocol with mild DKA with endocrinology guiding insulin management.
  • Avoid ordering C-peptide if concern for new type 1 diabetes, beta islet cells can be "stunned" with recent hyperglycemic states and may be falsely low.
  • SGLT2 inhibitors, are being prescribed much more often and can cause a euglycemic DKA, where acidosis and ketosis are present but there is no elevated BG.
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