Diabetic Ketoacidosis

# Overview
Diabetic ketoacidosis is diagnosed in the presence of symptoms like lethargy, fruity breath, thirst, weight loss, abdominal pain, and Kussmaul breathing and laboratory findings of hyperglycemia (Plasma glucose > 250 mg/dL), anion gap metabolic acidosis (pH < 7.3) and Serum bicarbonate < 15 mEq/L) and ketonemia/ ketonuria. The mainstay of treatment involves aggressive hydration with normal saline, glucose correction with insulin, potassium repletion and correction of acidosis and ketosis.

# Causes
The following are the causes of diabetic ketoacidosis (DKA):

## Common Causes
- Lack of insulin 
New diagnosis of Type 1 diabetes mellitus 
Non compliance with insulin in a known diabetic patient
Insufficient insulin dose in hospitalized patients  
- New diagnosis of Type 1 diabetes mellitus 
- Non compliance with insulin in a known diabetic patient
- Insufficient insulin dose in hospitalized patients  
- Drugs:
Antipsychotic agents  (clozapine, olanzapine, risperidone)
Illicit drugs (cocaine and alcohol)
Corticosteroids
Glucagon
Interferon
Pentamidine
Sympathomimetic agents (albuterol, dopamine, dobutamine, terbutaline, ritodrine, thiazide diuretics)
- Antipsychotic agents  (clozapine, olanzapine, risperidone)
- Illicit drugs (cocaine and alcohol)
- Corticosteroids
- Glucagon
- Interferon
- Pentamidine
- Sympathomimetic agents (albuterol, dopamine, dobutamine, terbutaline, ritodrine, thiazide diuretics)
- Infections:
Pneumonia
Sepsis
Urinary tract infection
- Pneumonia
- Sepsis
- Urinary tract infection

## Less common causes
Nonadherence to insulin treatment plans:
- Body image issues
- Financial problems
- Psychological factors
Physiological stressors:
- Acromegaly
- Thrombosis
- Cerebrovascular accident
- Cushing's disease
- Hemochromatosis
- Myocardial infarction
- Pancreatitis
- Pregnancy
- Psychological stress
- Shock/hypovolemia
- Trauma

# Diagnosis
- The diagnosis of diabetic ketoacidosis is made in the presence of:
Hyperglycemia- Plasma glucose > 250 mg/dL
Anion gap metabolic acidosis- pH < 7.3; Serum bicarbonate < 15 mEq/L
Ketonemia/ Ketonuria
- Hyperglycemia- Plasma glucose > 250 mg/dL
- Anion gap metabolic acidosis- pH < 7.3; Serum bicarbonate < 15 mEq/L
- Ketonemia/ Ketonuria
- Shown below is a table summarizing the diagnosis of Diabetic ketoacidosis according the the American Diabetes Association (ADA) guidelines.  

## Criteria for resolution
- According to American Diabetes Association, the following criteria must be met for labeling resolution of DKA:
Blood glucose <200mg/dl
- Blood glucose <200mg/dl
PLUS
- Any two of the following:
Bicarbonate greater than or equal to 15 mEq/L
Venous pH > 7.3
Anion gap less than equal to 12 mEq/L
- Bicarbonate greater than or equal to 15 mEq/L
- Venous pH > 7.3
- Anion gap less than equal to 12 mEq/L
- Bicarbonate level should not be relied upon to assess the resolution of DKA. This is because high volumes of 0.9 % saline (NaCl) may lead to hyperchloremia in patients. The hyperchloremic acidosis will lower the bicarbonate and thus lead to difficulty is assessing whether the ketosis has resolved. The hyperchloremic acidosis may cause renal vasoconstriction and be a cause of oliguria.
- DKA usually resolves in 24 hours with appropriate treatment.

# Treatment
Shown below is an algorithm summarizing the treatment of Diabetic ketoacidosis according the American Association of Clinical Endocrinologists (AACE) guidelines  and American Diabetes Association guidelines. 

## Step-wise approach to management of diabetic ketoacidosis

# Do's
- Correct hypovolemia and dehydration aggressively.
- In patients with potassium(K) < 3.3 mEq/L, fluids and potassium replacement must be done before initiating insulin therapy, to prevent further hypokalemia.
- Monitor plasma glucose levels every hourly.
- Monitor serum electrolytes and pH levels every 2-3 hourly.

# Don'ts
- Avoid rapid correction of plasma osmolality and serum sodium, to prevent fatal cerebral edema.
- Maximum reduction in plasma osmolality should be 3 mOsmol/kg per hour.