Diabetic Ketoacidosis DKA Criteria

Screens for presence of DKA based on diagnosis criteria by ADA.

Refer to the text below the calculator for more information on diabetic ketoacidosis, differential diagnosis and treatment.


Diabetic ketoacidosis (DKA) is defined by the biochemical triad of ketonaemia, hyperglycaemia and acidaemia and results from insulin deficiency in most cases, and can affect patient of all ages.

Timely diagnosis and intervention can significantly reduce risk of morbidity and mortality.


The American Diabetes Association diagnostic criteria for DKA are as follows:

Elevated serum glucose level; greater than 250 mg/dL (13.88 mmol/L);

Elevated serum ketone level;

pH less than 7.3;

Serum bicarbonate level less than 18 mEq/L (18 mmol/L).


1

Serum Glucose >250 mg/dL (13.8 mmol/L)

2

Anion gap

3

Arterial pH

4

Serum bicarbonate

5

Serum ketone

6

Urine ketone

7

Mental status

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Diabetic Ketoacidosis DKA criteria

Diabetic ketoacidosis is characterized by a serum glucose level greater than 250 mg/dL, a pH less than 7.3, a serum bicarbonate level less than 18 mEq/L, an elevated serum ketone level, and dehydration.

Insulin deficiency and infection are the main precipitating factors, whilst DKA can occur in persons of all ages:

■ 14% in patients older than 70 years;

■ 23% in patients between 51 and 70 years;

■ 27% in patients between 30 to 50 years of age;

■ 36% in patients younger than 30 years.

Acute medical illnesses of:

- the cardiovascular system: myocardial infarction, stroke, acute thrombosis;

- the gastrointestinal tract: bleeding, pancreatitis;

- the endocrine system: Cushing’s syndrome, hyperthyroidism, acromegaly;

can trigger DKA by causing dehydration, increase in insulin counterregulatory hormones or worsening of peripheral insulin resistance.

About 1 in 3 of all cases occur without a history of diabetes mellitus. Common symptoms include:

■ polyuria with polydipsia (98% of cases);

■ weight loss (81% of cases);

■ fatigue (62% of cases);

■ dyspnea (57% of cases);

■ vomiting (46% of cases);

■ preceding febrile illness (40% of cases);

■ abdominal pain (32% of cases);

The American Diabetes Association diagnostic criteria for DKA are as follows:

Elevated serum glucose level; greater than 250 mg/dL (13.88 mmol/L);

Elevated serum ketone level;

pH less than 7.3;

Serum bicarbonate level less than 18 mEq/L (18 mmol/L).

 

DKA differential diagnosis

To differentiate diabetic ketoacidosis from hyperosmolar hyperglycemic state, gastroenteritis, starvation ketosis, and other metabolic syndromes, the anion gap and the osmolar gap are determined as well as the following laboratory determinations are taken:

- A1C;

- blood urea nitrogen;

- creatinine;

- serum glucose;

- electrolytes;

- pH levels;

- serum ketones;

- complete blood count;

- urinalysis.

To differentiate between the three degrees of severity of diabetic ketoacidosis, the below can be employed:

Criteria Mild DKA Moderate DKA Severe DKA
Serum Glucose >250 mg/dL (13.8 mmol/L) >250 mg/dL (13.8 mmol/L) >250 mg/dL (13.8 mmol/L)
Anion gap   up to 12 mEq/L (up to 12 mmol/L) > 12 mEq/L (12 mmol/L) > 12 mEq/L (12 mmol/L)
Arterial pH 7.24 - 7.30 7.00 - 7.24 < 7.00
Serum bicarbonate 15 to 18 mEq/L (15 to 18 mmol/L) 10 to <15 mEq/L (10 to <15 mmol/L) < 10 mEq/L (<10 mmol/L)
Serum ketone Present Present Present
Urine ketone Present Present Present
Mental status Alert Alert / Drowsy Stupor / Coma
 

DKA treatment avenues

Appropriate treatment for DKA includes administering intravenous fluids and insulin, and monitoring glucose and electrolyte levels. Early diagnosis and intervention can reduce the risk and severity of possible complications (hyperglycemia and hypokalemia are the most frequent ones)

The therapeutic goals of DKA management include optimization of:

- volume status (replacing fluid deficit within 24-36 hours with the goal of 50% volume replacement within the first 12 hours) but caution in patients with CKD or CHF;

- hyperglycemia (transition to subcutaneous insulin by giving long-acting insulin 2 hours before the discontinuation of IV insulin);

- ketosis/acidosis;

- electrolyte abnormalities (bicarbonate therapy);

- potential precipitating factors.

Preventive patient education should include information on how to adjust insulin during times of illness and how to monitor glucose and ketone levels.

 

References

Westerberg DP. Diabetic ketoacidosis: evaluation and treatment. Am Fam Physician. 2013; 87(5):337-46.

Gosmanov AR, Kitabchi AE. Diabetic Ketoacidosis. Endotext.org

Kitabchi AE, Umpierrez GE, Fisher JN, Murphy MB, and Stentz FB. Thirty years of personal experience in hyperglycemic crises: diabetic ketoacidosis and hyperglycemic hyperosmolar state. The Journal of clinical endocrinology and metabolism 93: 1541-1552, 2008.


Specialty: Endocrinology

System: Endocrine

Objective: Diagnosis

No. Of Criteria: 7

Abbreviation: DKA

Article By: Denise Nedea

Published On: April 16, 2020

Last Checked: April 16, 2020

Next Review: April 16, 2025