Obvious DKA: In some cases the history and physical examination are strongly suggestive of DKA.Among patients who initially presented with DKA, a reduction of the beta-hydroxybutyrate level below 3 mM: Consistent with DKA.
0.6-1 mM: Mild ketosis, may consider adjustment of insulin regimen. Beta-hydroxybutyrate level is the gold standard for defining the presence and extent of ketoacidosis in DKA. ( 32763063) For example, starvation ketoacidosis is a more common cause of urinary ketones in most contexts. The specificity of a positive measurement of urinary ketones is low, so a positive urinary measurement of ketones doesn't establish a diagnosis of DKA. ( 32771260, 10459090) False negatives may occur in patients with highly acidic urine. This test has a high sensitivity for DKA (98-99%), with urinary ketones are generally being ≧2+. The urinary ketone dipstick tests for acetoacetate. Therefore, an elevated anion gap does not necessarily imply DKA! This is especially true among patients with chronic renal failure, who may have a chronically elevated anion gap. Anion gap may be elevated due to a variety of causes (with the differential diagnosis explored here). Don't make this unnecessarily complicated. Please don't correct for albumin, glucose, or potassium. Using this formula, an elevated anion gap is above 10-12 mEq/L. Three ways to evaluate for ketoacidosis (#1) anion gap (Na – Cl – 10) 18 mM, to expedite discontinuation of the insulin infusion in a timely fashion. Anion gap is falling, but bicarbonate is not rising appropriately. NAGMA often emerges during the course of a DKA resuscitation. Management of non-anion-gap metabolic acidosis ( more) Most patients: provide their entire daily requirement of basal insulin. New diagnosis of diabetes: start 0.25 U/kg glargine. #Just cause 3 rebel backup full
Patients should receive their full daily requirement of basal, long-acting insulin as a single dose of glargine:.Start basal insulin early (well before the anion gap has closed).Patient received full dose of basal insulin >2 hours previously.2nd: Infuse LR at ~150-200 ml/hr, until glucose 5.3 mM, if renal function preserved.1st: Bolus with lactated Ringers (LR) if substantial volume depletion (which is usually the case).If the cause of DKA is unclear: blood cultures +/- urine culture, chest X-ray, perhaps CT abdomen/pelvis to evaluate for septic focus, possibly lipase (noting that DKA itself can increase lipase 14578269), troponin if genuine suspicion for ischemia.If unclear whether patient has DKA: beta-hydroxybutyrate & lactate levels.Minimum evaluation for a patient with DKA: Electrolytes including Ca/Mg/Phos, complete blood count with differential, urinalysis, EKG, pregnancy test as appropriate.Monitoring & management of DKA recurrenceĭKA management checklist ✅ diagnostic evaluation ( more).Management of severe or refractory ketoacidosis.
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