Diabetic Ketoacidosis Diagnostic Criteria and Management

Diagnostic Criteria

The American Diabetes Association defines classic DKA using three main criteria: blood glucose >250 mg/dL, venous pH <7.3 and serum bicarbonate <15 mEq/L, and presence of moderate ketonuria or ketonemia 1
Classic DKA can be classified into severity levels: Mild DKA (Venous pH 7.25-7.30, bicarbonate 15-18 mEq/L), Moderate DKA (Venous pH 7.00-7.24, bicarbonate 10-15 mEq/L), and Severe DKA (Venous pH <7.00, bicarbonate <10 mEq/L) 1

The underlying mechanism for both classic and euglycemic DKA is reduction in effective insulin action, elevation of counterregulatory hormones, and release of free fatty acids leading to ketone production 2

For euglycemic DKA, continue insulin therapy despite normal glucose levels, add dextrose to hydrating solution while continuing insulin infusion, and monitor for resolution based on pH >7.3, bicarbonate ≥18 mEq/L, and anion gap ≤12 mEq/L, not just glucose levels 3
Interrupting insulin therapy when glucose normalizes before ketoacidosis resolves should be avoided 3
Relying solely on urine ketones rather than direct measurement of β-hydroxybutyrate in blood should be avoided 3