Diabetic Ketoacidosis: Treat Ketones, Not Just Glucose
Diagnostic Framework
- DKA requires all three of the following:
- Diabetes history or glucose at least 200 mg/dL.
- Ketosis.
- Metabolic acidosis.
- Prefer blood beta-hydroxybutyrate when available.
- A value at least 3.0 mmol/L supports DKA.
- Neither glucose alone nor an anion gap alone establishes the diagnosis.
Common Triggers
- Infection.
- Missed insulin or new diabetes.
- Myocardial infarction, stroke, or pancreatitis.
- Steroids.
- SGLT2 inhibitors.
Initial Resuscitation and Monitoring
- Use balanced crystalloids when available. Normal saline remains acceptable when balanced fluids are unavailable.
- Reassess serially:
- Hemodynamics and urine output.
- Electrolytes.
- Glucose and acid-base status.
Potassium Before Insulin
- Potassium determines whether insulin can safely begin.
- If potassium is below 3.5 mEq/L:
- Hold insulin.
- Replace potassium first.
- If potassium is 3.5 to 5.0 mEq/L:
- Add 20 to 30 mEq potassium to each liter of intravenous fluid.
- If potassium exceeds 5.0 mEq/L:
- Withhold initial replacement.
- Monitor closely.
- Aim for potassium 4 to 5 mEq/L.
Insulin and Dextrose Strategy
- Once potassium is safe, use intravenous insulin.
- Target a glucose decline of 50 to 70 mg/dL each hour.
- When glucose falls below 200 mg/dL:
- Add dextrose.
- Continue insulin until ketosis and acidosis resolve.
- Give basal insulin 2 to 4 hours before discontinuing the intravenous insulin infusion.
Biochemical Resolution
- The endpoint is biochemical resolution, not euglycemia.
- When beta-hydroxybutyrate is available, resolution requires:
- Plasma ketones below 0.6 mmol/L.
- Venous pH at least 7.30 or bicarbonate at least 18 mmol/L.
- Glucose ideally below 200 mg/dL.
- Do not use anion-gap normalization as the primary endpoint. Saline-related hyperchloremic acidosis can persist after ketone clearance.
SGLT2-Associated Euglycemic DKA
- Euglycemic DKA may occur with glucose below 200 mg/dL.
- Stop the SGLT2 inhibitor on admission.
- Add dextrose early so insulin can continue until ketosis and acidosis resolve.
Practical Takeaway
- Key point: Treat ketone clearance and metabolic-acidosis resolution, not glucose alone.
- This adult educational summary does not replace local DKA, ICU, perioperative, or endocrinology protocols.
YouTube: https://youtu.be/UUGJjt5h4FY
