How do you know when DKA is resolved?
“DKA is resolved when 1) plasma glucose is <200–250 mg/dL; 2) serum bicarbonate concentration is ≥15 mEq/L; 3) venous blood pH is >7.3; and 4) anion gap is ≤12.
In general, resolution of hyperglycemia, normalization of bicarbonate level, and closure of anion gap is sufficient to stop insulin infusion.” Diabetes Metab 2014
“DKA is resolved when 1) the glucose level is less than 200 mg per dL, 2) the pH is greater than 7.3, and 3) the bicarbonate level is 18 mEq per L or higher.” AFP 2013
In my practice, I use elements of both of the above definitions. I go with the values of the 3 elements listed in the AFP definition. In addition to that, I follow the anion gap to see it close to be ≤12
-Glucose level of < 200 mg/dL
-Normalization of AG (to less than 12mEq/L),
-Bicarbonate level of 18 or higher,
-Venous blood pH is >7.3
The first three items can be checked with an accucheck and a BMP.
Some doctors check a blood beta-hydroxybutyrate level.
Pearls
- Anion gap is calculated by subtracting the sum of chloride and bicarbonate from measured (not corrected) sodium concentration.
- The anion gap can improve even before the restoration of serum bicarbonate due to hyperchloremia from the normal saline infusion.
- Venous pH is adequate to assess the degree of acidosis with the consideration that it is 0.02–0.03 lower than arterial blood. You don’t need an ABG.
- If plasma glucose is <200 mg/dL but bicarbonate and pH are not normalized, insulin infusion must be continued and dextrose-containing intravenous fluids started. The latter approach will continue to suppress ketogenesis while preventing hypoglycemia.
- Insulin deficiency is the main precipitating factor of DKA. So make sure insulin continues to run until the DKA is resolved. When it resolves you transition from insulin drip to SC but make sure they have adequate SC insulin as well.
Reference
Diabetes Metab Syndr Obes. 2014; 7: 255–264. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4085289/
Am Fam Physician. 2013 Mar 1;87(5):337-346. https://www.ncbi.nlm.nih.gov/pubmed/23547550