Cerebral edema is associated with a mortality rate of up to 70 percent. When a blood glucose concentration of mg per dL has been achieved, the continuous or hourly insulin dosage can be reduced to 0.

The insulin and fluid regimens are continued until ketoacidosis is controlled. This requires the achievement of at least two of these acid-base parameters: a serum bicarbonate concentration of greater than 18 mEq per L, a venous pH of 7.

Although the typical potassium deficit in diabetic ketoacidosis is to mEq to mmol , most patients are hyperkalemic at the time of diagnosis because of the effects of insulinopenia, hyperosmolality and acidemia.

One protocol entails using insulin and intravenous fluids until the serum potassium concentration is less than 5. At this time, potassium chloride is added to intravenous fluids in the amount of 20 to 40 mEq per L. The exact amount of potassium that is administered depends on the serum potassium concentration.

When the serum potassium level is less than 3. If the serum potassium is greater than 3. The goal is to maintain the serum potassium concentration in the range of 4 to 5 mEq per L 4 to 5 mmol per L.

In general, supplemental bicarbonate therapy is no longer recommended for patients with diabetic ketoacidosis, because the plasma bicarbonate concentration increases with insulin therapy.

Retrospective reviews and prospective randomized studies have failed to identify changes in morbidity or mortality with sodium bicarbonate therapy in patients who presented with a pH of 6. Therefore, the use of bicarbonate in a patient with a pH greater than 7. Furthermore, bicarbonate therapy carries some risks, including hypokalemia with overly rapid administration, paradoxic cerebrospinal fluid acidosis and hypoxia.

Some authorities, however, recommend bicarbonate administration when the pH is less than 7. If bicarbonate is used, it should be given as a nearly isotonic solution, which can be approximated by the addition of one ampule of sodium bicarbonate in mL of sterile water. The bicarbonate solution is administered over a one-hour period.

A small percentage of patients who have diabetic ketoacidosis present with metabolic acidosis and a normal anion gap. Therefore, they have fewer ketones available for the regeneration of bicarbonate during insulin administration.

Osmotic diuresis leads to increased urinary phosphate losses. During insulin therapy, phosphate reenters the intracellular compartment, leading to mild to moderate reductions in the serum phosphate concentration. Adverse complications of hypophosphatemia are uncommon and occur primarily in patients with severe hypophosphatemia a serum phosphate concentration of less than 1.

Prospective studies have indicated no clinical benefit for phosphate replacement in the treatment of diabetic ketoacidosis, and excessive phosphate replacement may contribute to hypocalcemia and soft tissue metastatic calcification. One protocol is to administer two thirds of the potassium as potassium chloride and one third as potassium phosphate.

The use of phosphate for this purpose reduces the chloride load that might contribute to hyperchloremic acidosis and decreases the likelihood that the patient will develop severe hypophosphatemia during insulin therapy.

When diabetic ketoacidosis has been controlled, subcutaneous insulin therapy can be started. The half-life of regular insulin is less than 10 minutes.

Therefore, to avoid relapse of diabetic ketoacidosis, the first subcutaneous dose of regular insulin should be given at least one hour before intravenous insulin is discontinued. In patients who are unable to eat, 5 percent dextrose in hypotonic saline solution is continued at a rate of to mL per hour.

Blood glucose levels are monitored every four hours, and regular insulin is given subcutaneously every four hours using a sliding scale Figure 2. When patients are able to eat, multidose subcutaneous therapy with both regular short-acting and intermediate-acting insulin may be given.

In patients with newly diagnosed diabetes, an initial total insulin dosage of 0. A typical regimen is two thirds of the total daily dosage before breakfast and one third of the total daily dosage before dinner, with the insulin doses consisting of two-thirds NPH intermediate-acting insulin and one-third regular short-acting insulin.

Patients with known diabetes can typically be given the dosage they were receiving before the onset of diabetic ketoacidosis. Symptomatic cerebral edema occurs primarily in pediatric patients, particularly those with newly diagnosed diabetes.

No single factor predictive for cerebral edema has yet been identified. As noted previously, however, overly rapid rehydration or overcorrection of hyperglycemia appears to increase the risk of cerebral edema.

Onset of headache or mental status changes during therapy should lead to consideration of this complication. Intravenous mannitol in a dosage of 1 to 2 g per kg given over 15 minutes is the mainstay of therapy.

Prompt involvement of a critical care specialist is prudent. Adult respiratory distress syndrome ARDS is a rare but potentially fatal complication of the treatment of diabetic ketoacidosis. Patients with an increased alveolar to arterial oxygen gradient AaO2 and patients with pulmonary rales on physical examination may be at increased risk for ARDS.

Monitoring of oxygen saturation with pulse oximetry may assist in the management of such patients. Hyperchloremic metabolic acidosis with a normal anion gap typically persists after the resolution of ketonemia. This acidosis has no adverse clinical effects and is gradually corrected over the subsequent 24 to 48 hours by enhanced renal acid excretion.

No randomized prospective studies have evaluated the optimal site of care for patients with diabetic ketoacidosis. The response to initial therapy in the emergency department can be used as a guideline for choosing the most appropriate hospital site i.

Admission to a step-down or intensive care unit should be considered for patients with hypotension or oliguria refractory to initial rehydration and for patients with mental obtundation or coma with hyperosmolality total osmolality of greater than mOsm per kg of water.

Most patients can be treated in step-down units or on general medical wards in which staff members have been trained in on-site blood glucose monitoring and continuous intravenous insulin administration. Milder forms of diabetic ketoacidosis can be treated in the emergency department using the same treatment guidelines described in this review.

Successful outpatient therapy requires the absence of severe intercurrent illness, an alert patient who is able to resume oral intake and the presence of mild diabetic ketoacidosis pH of greater than 7. With the use of standardized written treatment guidelines and flow sheets for monitoring therapeutic response, the mortality rate for patients with diabetic ketoacidosis is now less than 5 percent.

These outcomes have not been altered by the specialty of the primary treating physicians e. An educational program should include sick-day management instructions i.

Patients should not discontinue insulin therapy when they are ill, and they should contact their physician early in the course of illness. Indications for hospitalization include greater than 5 percent loss of body weight, respiration rate of greater than 35 per minute, intractable elevation of blood glucose concentrations, change in mental status, uncontrolled fever and unresolved nausea and vomiting.

Umpierrez GE, Khajavi M, Kitabchi AE. Review: diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic syndrome. Am J Med Sci. Umpierrez GE, Kelly JP, Navarrete JE, Casals MM, Kitabchi AE.

Hyperglycemic crises in urban blacks. Arch Intern Med. Ennis ED, Stahl EJ, Kreisberg RA. Diabetic ketoacidosis. In: Porte D Jr, Sherwin RS, eds. Stamford, Conn. Your breath smells fruity. You have multiple signs and symptoms of DKA.

Your treatment will likely include: Replacing fluids you lost through frequent urination and to help dilute excess sugar in your blood. Replacing electrolytes minerals in your body that help your nerves, muscles, heart, and brain work the way they should.

Too little insulin can lower your electrolyte levels. Receiving insulin. Insulin reverses the conditions that cause DKA. Taking medicines for any underlying illness that caused DKA, such as antibiotics for an infection. Keep your blood sugar levels in your target range as much as possible.

Take medicines as prescribed, even if you feel fine. Learn More. Learn About DSMES Living With Diabetes 4 Ways To Take Insulin Low Blood Sugar Hypoglycemia.

Last Reviewed: December 30, Source: Centers for Disease Control and Prevention. Facebook Twitter LinkedIn Syndicate. home Diabetes Home. Electrolytes are electrically charged minerals that help your body, including the heart and nerves, function properly. Electrolyte replacement is also commonly done through an IV.

The emergency care team will also monitor several other blood test results that indicate when insulin therapy is no longer needed. When your blood sugar and other test readings are within an acceptable range, your doctor will work with you to help you avoid DKA in the future.

DKA occurs when insulin levels are low. Our bodies need insulin to use the available glucose in the blood. Turning fat into energy produces ketones. When too many ketones build up, your blood becomes acidic. This is diabetic ketoacidosis. Although DKA is less common in people who have type 2 diabetes, it does occur.

A diagnosis of ketosis-prone diabetes is more likely for:. Testing for ketones is one of the first steps for diagnosing DKA. If you have type 1 diabetes, you should have a supply of home ketone tests.

These test either your urine or your blood for the presence of ketones. According to the American Diabetes Association , you should test for ketones:. Urine test strips change color to signal the presence of ketones in your urine.

The indicator on the strip will change color. Compare the test strip to the results chart. Blood ketone testers are also available. These are usually combination devices that can measure both glucose levels and ketone levels. The test strip is inserted into a monitor device to test for the presence of ketones in your blood.

A doctor will likely do a test to confirm the presence of ketones in your urine. They will usually also test your blood sugar level. Other tests your doctor may order include:.

There are many ways to prevent DKA. You can lower your risk of DKA with proper management of your diabetes:. Call your doctor if you detect moderate or high ketones in a home test.

Early detection is essential. DKA is serious, but it can be prevented. Follow your diabetes treatment plan and be proactive about your health. They can adjust your treatment plan or help you come up with solutions for better managing your diabetes. Read this article in Spanish.

Our experts continually monitor the health and wellness space, and we update our articles when new information becomes available. VIEW ALL HISTORY. In an effort to control blood sugar and weight, some people are turning to the ketogenic diet for managing type 2 diabetes.

Diabetic ketoacidosis DKA is a serious complication of diabetes that can be life-threatening. DKA is most common among people with type 1 diabetes. People with type 2 diabetes can also develop DKA. Instead, your liver breaks down fat for fuel, a process that produces acids called ketones.

When too many ketones are produced too fast, they can build up to dangerous levels in your body. High ketones can be an early sign of DKA, which is a medical emergency.

Checking your ketones at home is simple. You should also test for ketones if you have any of the symptoms of DKA. Call your doctor if your ketones are moderate or high. Elevated ketones are a sign of DKA, which is a medical emergency and needs to be treated immediately. Your treatment will likely include:.

DSMES services are a vital tool to help you manage and live well with diabetes while protecting your health. Skip directly to site content Skip directly to search.

Español Other Languages. Diabetic Ketoacidosis. Español Spanish Print. Minus Related Pages. High ketones? Call your doctor ASAP. Your breath smells fruity.

You have multiple signs and symptoms of DKA. Your treatment will likely include: Replacing fluids you lost through frequent urination and to help dilute excess sugar in your blood.

Electrolyte replacement. Electrolytes are minerals in the blood, such as sodium, potassium and chloride, that carry an electric charge. Too little insulin can lower the level of several electrolytes in the blood. IV electrolytes are given to help keep the heart, muscles and nerve cells working as they should.

Insulin therapy. Insulin reverses diabetic ketoacidosis. In addition to fluids and electrolytes, insulin is given, usually through a vein.

Request an appointment. Call or your local emergency number if: You can't reach your care provider Your symptoms are getting worse Your symptoms are already very bad A health care provider who sees you for possible diabetic ketoacidosis needs answers to these questions as quickly as possible: What are your symptoms?

When did your symptoms develop? Are they getting worse? Have you been diagnosed with diabetes? Have you recently checked your blood sugar level? Have you recently checked your ketone level?

Have you lost your appetite? Can you keep fluids down? Are you having trouble breathing? Do you have chest pain? Have you had a recent illness or infection? Have you had recent stress or trauma?

Have you recently used alcohol or recreational drugs? How closely have you been following your diabetes treatment plan? How well have you been managing your diabetes just before these symptoms started? By Mayo Clinic Staff.

Oct 06, Show References. DKA ketoacidosis and ketones. American Diabetes Association. Accessed Sept. Diabetic ketoacidosis DKA.

Merck Manual Professional Version. Hirsch IB, et al. Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Clinical features, evaluation, and diagnosis. Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment.

Ferri FF. Diabetic ketoacidosis. In: Ferri's Clinical Advisor Elsevier; Evans K. Diabetic ketoacidosis: Update on management. Clinical Medicine. Associated Procedures.

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