DKA Study Notes 2025

 Definition:

• Acute, life-threatening complication of diabetes (mostly type 1, but can occur in type 2).

• Characterized by:

  1. Hyperglycemia

  2. Ketosis

  3. Metabolic acidosis

Pathophysiology

• Absolute or relative insulin deficiency + ↑ counterregulatory hormones (glucagon, cortisol, catecholamines, growth hormone).

• ↓ Glucose uptake → hyperglycemia → osmotic diuresis → dehydration & electrolyte loss.

• ↑ Lipolysis → free fatty acids → hepatic ketogenesis → ketone bodies (acetoacetate, β-hydroxybutyrate).

• Accumulation of ketones → anion gap metabolic acidosis.

Precipitating Factors

• Infection (most common).

• Missed insulin doses.

• Myocardial infarction, stroke.

• Pancreatitis.

• Medications: steroids, thiazides, sympathomimetics, SGLT2 inhibitors (can also cause euglycemic DKA).

Clinical Features

Symptoms

• Polyuria, polydipsia, polyphagia.

• Nausea, vomiting, abdominal pain.

• Fatigue, weakness.

Signs

• Dehydration (dry mucous membranes, poor skin turgor, hypotension, tachycardia).

• Kussmaul respirations (deep, rapid breathing → respiratory compensation for acidosis).

• Fruity/acetone breath odor.

• Altered mental status (confusion, drowsiness, coma in severe cases).

Laboratory Findings

• Glucose: > 250 mg/dL (though lower in euglycemic DKA).

• Arterial pH: < 7.3.

• Serum bicarbonate (HCO₃⁻): < 18 mEq/L.

• Anion gap: elevated.

• Ketones: positive in serum and urine (β-hydroxybutyrate most specific).

• Electrolytes:

  • Total body K⁺ is low, but serum K⁺ may be normal or elevated initially due to acidosis/insulin deficiency.

  • Na⁺ may appear low due to hyperglycemia (pseudohyponatremia).

Management (ABCDE approach)

1. Airway/Breathing/Circulation – stabilize first.

2. Fluid replacement:

   • Isotonic saline (0.9% NaCl) initially.

   • Replace deficits gradually (6–9 L over 24 hrs).

3. Insulin therapy:

   • IV regular insulin after fluids started.

   • Corrects hyperglycemia & suppresses ketogenesis.

4. Potassium management:

   • If K⁺ < 3.3 → replace K⁺ before insulin.

   • If 3.3–5.0 → replace K⁺ with insulin therapy.

   • If > 5.0 → monitor, no replacement initially.

5. Bicarbonate therapy:

   • Only if pH < 6.9.

6. Monitor closely:

   • Vitals, neuro status, glucose, electrolytes, urine output, anion gap.

Complications

• Cerebral edema (especially in children).

• Hypoglycemia (from treatment).

• Hypokalemia (from insulin + correction).

• ARDS, shock if severe.

Prognosis

• Good with prompt treatment.

• Mortality higher in elderly, comorbidities, delayed diagnosis.

Key Takeaways:

• DKA = hyperglycemia + ketosis + acidosis.

• Always correct fluids first, then insulin, while managing potassium.

• Search for precipitating cause (infection, MI, missed insulin).