endocrine and metabolic disorders
Diabetic Ketoacidosis (DKA)
Diagnosis of DKA
Arterial pH Serum ketones Calculation of anion gap In patients suspected of having diabetic ketoacidosis, serum electrolytes, bloodureanitrogen (BUN) and creatinine, glucose, ketones, and osmolarity should be measured. Urine should be tested for ketones. Patients who appear significantly ill and those with positive ketones should have arterial blood gas measurement. 12 and serum ketones. Guidelines differ on specific levels of hyperglycemia to be included in the diagnostic criteria for DKA. A blood glucose level > 200 (11.1 mmol/L) or > 250 mg/dL (13.8 mmol/L) is most often specified; however, because DKA can occur in patients with normal or mildly elevated glucose levels, some guidelines do not include a specific level ( Diagnosis references ). A presumptive diagnosis may be made when urine glucose and ketones are positive on urinalysis. Urine test strips and some assays for serum ketones may underestimate the degree of ketosis because they detect acetoacetic acid and not beta-hydroxybutyric acid, which is usually the predominant ketoacid. Blood beta-hydroxybutyrate can be measured, or treatment can be initiated based on clinical suspicion and the presence of anion gap acidosis if serum or urine ketones are low. Symptoms and signs of a triggering illness should be pursued with appropriate studies (eg, cultures, imaging studies). Adults should have an ECG to screen for acute myocardial infarction and to help determine the significance of abnormalities in serum potassium. Other laboratory abnormalities include Hyponatremia None Elevated serum creatinine Elevated plasma osmolality Hyperglycemia may cause dilutional hyponatremia, so measured serum sodium is corrected by adding 1.6 mEq/L (1.6 mmol/L) for each 100 mg/dL (5.6 mmol/L) elevation of serum glucose over 100 mg/dL (5.6 mmol/L). To illustrate, for a patient with serum sodium of 124 mEq/L (124 mmol/L) and glucose of 600 mg/dL (33.3 mmol/L), add 1.6 ([600−100]/100) = 8 mEq/L (8 mmol/L) to 124 for a corrected serum sodium of 132 mEq/L (132 mmol/L). As acidosis is corrected, serum potassium drops. An initial potassium level<4.5 mEq/L (< 4.5 mmol/L) indicates marked potassium depletion and requires immediate potassium supplementation. Serum amylase and lipase are often elevated, even in the absence of Overview of Pancreatitis (which may be present in patients with 1.Buse JB, Wexler DJ, Tsapas A, et al: 2019 Update to: Management of Hyperglycemia in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD).Diabetes Care43(2):487–493, 2020. doi: 10.2337/dci19-0066 2.Garber AJ, Handelsman Y, Grunberger G, et al: Consensus statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the comprehensive type 2 diabetes management algorithm--2020 executive summary.Endocrine Practice26:107–139, 2020. 