eMedicine Specialties > Endocrinology > Diabetes Mellitus

Diabetic Ketoacidosis: Differential Diagnoses & Workup

Author: Osama Hamdy, MD, MB, BCh, PhD, Medical Director, Obesity Clinical Program, Joslin Diabetes Center, Assistant Professor of Medicine, Harvard Medical School, Boston, MA
Contributor Information and Disclosures

Updated: Sep 1, 2009

Differential Diagnoses

Alcoholic Ketoacidosis
Sepsis, Bacterial
Hyperosmolar Coma
Toxicity, Salicylate
Lactic Acidosis
Metabolic Acidosis
Pancreatitis, Acute

Other Problems to Be Considered

Bacteremia and sepsis
Dehydration due to gastroenteritis

Workup

Laboratory Studies

  • Urine
    • This test is highly positive for glucose and ketones by dipstick testing. Rarely, urine is negative for ketones because most of the available laboratory tests can detect only acetoacetate, while the predominant ketone in severe untreated diabetic ketoacidosis (DKA) is beta hydroxybutyrate. When the clinical condition improves with treatment, the urine test result becomes positive due to the returning predominance of acetoacetate.
    • Urine culture helps to identify any possible infecting organisms.
  • Blood and plasma
    • The blood glucose level usually is higher than 250 mg/dL.
    • Serum ketones are present. Blood beta-hydroxybutyrate (beta-OHB) levels measured by a reagent strip (Ketostix, N-Multistix, and Labstix) and serum ketone levels assessed by the nitroprusside reaction are equally effective in diagnosing DKA among uncomplicated cases.
    • Arterial blood gases (ABG) frequently show typical manifestations of metabolic acidosis, low bicarbonate, and low pH (<7.2).
    • Serum potassium levels initially are high or within the reference range due to the extracellular shift of potassium in exchange of hydrogen, which is accumulated in acidosis, in spite of severely depleted total body potassium.
    • The serum sodium level usually is low.
    • The serum chloride levels and phosphorus levels always are low.
    • The anion gap is elevated ([Na + K] - [Cl + HCO3] >13 mEq/L).
    • Plasma osmolarity usually is increased (>290 mOsm/L). If plasma osmolarity cannot be directly measured, it may be calculated with this formula: plasma osmolarity = 2 (Na + K) + BUN/3 + glucose/18. Urine osmolarity also is increased.
    • Even in the absence of infection, CBC shows increased WBC count.
    • BUN frequently is increased.
    • Blood culture findings may help to identify any possible infecting organisms.
  • Frequency of laboratory studies
    • Blood tests for glucose should be performed hourly (until patient is stable, then every 6 h).
    • Serum electrolyte determinations should be obtained hourly (until patient is stable, then every 6 h).
    • BUN should be performed initially.
    • ABG should be performed initially, followed with bicarbonate as necessary.

Imaging Studies

  • Plain chest radiograph may reveal signs of pneumonia.
  • If it occurs during therapy, magnetic resonance imaging (MRI) is helpful in detecting early cerebral edema and should only be ordered if altered consciousness is present.5

Other Tests

  • Electrocardiogram (ECG)
    • This test may reveal signs of acute myocardial infarction that could be painless in patients with diabetes, particularly in those with autonomic neuropathy.
    • T-wave changes may produce the first warning sign of disturbed serum potassium levels.
    • Low T wave and apparent U wave always signify hypokalemia, while peaked T wave is observed in hyperkalemia.
  • ECG should be performed every 6 hours during the first day, unless the patient is monitored.

More on Diabetic Ketoacidosis

Overview: Diabetic Ketoacidosis
Differential Diagnoses & Workup: Diabetic Ketoacidosis
Treatment & Medication: Diabetic Ketoacidosis
Follow-up: Diabetic Ketoacidosis
References
Further Reading
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References

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  36. Wagner A, Risse A, Brill HL, et al. Therapy of severe diabetic ketoacidosis. Zero-mortality under very-low-dose insulin application. Diabetes Care. May 1999;22(5):674-7. [Medline].

  37. Yan SH, Sheu WH, Song YM, Tseng LN. The occurrence of diabetic ketoacidosis in adults. Intern Med. Jan 2000;39(1):10-4. [Medline].

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Further Reading

Related eMedicine topics:
Diabetes Mellitus, Type 1 [Endocrinology]
Diabetes Mellitus, Type 1 [Pediatrics: General Medicine]
Diabetes Mellitus, Type 1 - A Review
Diabetes Mellitus, Type 2 [Endocrinology]
Diabetes Mellitus, Type 2 [Pediatrics: General Medicine]
Diabetes Mellitus, Type 2 - A Review
Diabetic Ketoacidosis [Emergency Medicine]
Diabetic Ketoacidosis [Pediatrics: Cardiac Disease and Critical Care Medicine]
Disorders of Carbohydrate Metabolism
Metabolic Acidosis [Emergency Medicine]
Metabolic Acidosis [Nephrology]
Pediatrics, Diabetic Ketoacidosis

Clinical guidelines:
 Care of children and adolescents with type 1 diabetes: a statement of the American Diabetes Association. American Diabetes Association - Professional Association.  2005 Jan.  27 pages.  NGC:004193

Hyperglycemic crises in diabetes. American Diabetes Association - Professional Association.  2000 Oct (revised 2001; republished 2004 Jan).  9 pages.  NGC:003428

Clinical trials:
Cerebral Edema in Pediatric Diabetic Ketoacidosis

Ketosis Prone Diabetes in African-Americans

Use of Insulin Glargine to Treat Diabetic Ketoacidosis

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Keywords

diabetic ketoacidosis, ketoacidosis, acidosis, DKA, metabolic acidosis, diabetes, hyperglycemia, ketonuria, diabetes mellitus, type 1 diabetes, diabetes type 1, type 2 diabetes, diabetes type 2, insulin, human insulin, type 1 DM, type 2 DM,  ketogenesis, ketones, ketoacids, acetone, beta hydroxybutyrate, acetoacetate, Kussmaul respirations, increased thirst, polydipsia, increased urination, polyuria

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Contributor Information and Disclosures

Author

Osama Hamdy, MD, MB, BCh, PhD, Medical Director, Obesity Clinical Program, Joslin Diabetes Center, Assistant Professor of Medicine, Harvard Medical School, Boston, MA
Osama Hamdy, MD, MB, BCh, PhD is a member of the following medical societies: American Association of Clinical Endocrinologists and American Diabetes Association
Disclosure: Takeda phamaceutical North America Honoraria Speaking and teaching; Merck Inc Honoraria Speaking and teaching; Novo Nordisk Honoraria Speaking and teaching; Amylin Pharmaceutical Honoraria Speaking and teaching; Aventis Honoraria Speaking and teaching

Medical Editor

David S Schade, MD, Chief, Division of Endocrinology and Metabolism, Professor, Department of Internal Medicine, University of New Mexico School of Medicine and Health Sciences Center
David S Schade, MD is a member of the following medical societies: American College of Physicians, American Diabetes Association, American Federation for Medical Research, Endocrine Society, New Mexico Medical Society, New York Academy of Sciences, and Society for Experimental Biology and Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Don S Schalch, MD, Professor Emeritus, Department of Internal Medicine, Division of Endocrinology, University of Wisconsin Hospitals and Clinics
Don S Schalch, MD is a member of the following medical societies: American Diabetes Association, American Federation for Medical Research, Central Society for Clinical Research, and Endocrine Society
Disclosure: Nothing to disclose.

CME Editor

Mark Cooper, MBBS, PhD, FRACP, Head, Diabetes & Metabolism Division, Baker Heart Research Institute, Professor of Medicine, Monash University
Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD, Professor of Medicine, St Louis University School of Medicine
George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Medical Practice Executives, American College of Physician Executives, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical Research, Endocrine Society, International Society for Clinical Densitometry, and Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.

 
 
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