eMedicine Specialties > Endocrinology > Diabetes Mellitus

Diabetic Ketoacidosis: Follow-up

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

Follow-up

Further Inpatient Care

  • Patients are not usually discharged from the hospital unless they have switched back to their daily insulin regimen without recurrence of ketosis. When the condition is stable, pH is greater than 7.3, and bicarbonate is greater than 18 mEq/L, the patient is allowed to eat a meal preceded by an SC dose of regular insulin. Insulin infusion can be discontinued 30 minutes later. If the patient is still nauseated and cannot eat, continue dextrose infusion and administer regular or ultra–short-acting insulin SC every 4 hours according to blood glucose level, while trying to maintain blood glucose values at 100-180 mg/dL.
  • In established patients with diabetes, SC long-acting insulin (eg, insulin glargine, Detemir, Ultralente) should be initiated back at the same dose that was used prior to diabetic ketoacidosis. However, if neutral protamine Hagedorn (NPH) insulin was previously used, start back at the usual dose only when the patient eats well and is able to retain meals without vomiting; otherwise, the dose should be reduced to avoid hypoglycemia during its peak efficacy period.
  • In newly diagnosed patients with type 1 DM, a careful estimate of the long-acting insulin dose should be considered. Starting with smaller doses generally is recommended to avoid unneeded hypoglycemia.

Further Outpatient Care

  • Psychological counseling of young children and adolescents usually is helpful.

Complications

  • Cerebral edema is a serious, major complication that may evolve during treatment of diabetic ketoacidosis (DKA). Be extremely cautious to avoid cerebral edema during initiation of therapy. Deterioration of the level of consciousness in spite of improved metabolic state usually indicates the occurrence of cerebral edema. MRI usually is used to confirm the diagnosis. If cerebral edema occurs at initiation of therapy, it usually worsens during the course of treatment. Clinical cerebral edema is rare and carries the highest mortality rate. Although mannitol (0.25-1 g/kg IV) and dexamethasone (2-4 mg q6-12h) frequently are used in this situation, no specific medication has proven to be useful in such instances.
  • Cardiac dysrhythmia may occur secondary to severe hypokalemia and/or acidosis either initially or as a result of therapy. Usually, correction of the cause is sufficient to treat cardiac dysrhythmia, but, if it persists, consultation with a cardiologist is mandatory. Performing cardiac monitoring on patients with DKA during correction of electrolytes always is advisable.
  • Pulmonary edema may occur for the same reasons as cerebral edema. Although it is rare, be cautious of possible overcorrection of fluid loss. Diuretics and oxygen therapy are often sufficient for the management of pulmonary edema.
  • Nonspecific myocardial injury may occur in severe DKA, which is associated with minute elevations of myocardial biomarkers (troponin T and CK-MB) and initial ECG changes compatible with myocardial infarction (MI). Acidosis and very high levels of free fatty acids could cause membrane instability and biomarker leakage. Coronary arteriography usually is normal, and patients usually recover fully without further evidence of ischemic heart disease. Regardless of the pathogenesis, the presence of minute biomarker elevations and ECG changes do not necessarily signify MI in DKA.
  • Microvascular changes consistent with diabetic retinopathy have been reported prior to and after treatment of DKA; however, the blood-retinal barrier does not experience the same degree of perturbation as the blood-brain barrier does.

Prognosis

  • The prognosis of properly treated patients with diabetic ketoacidosis is excellent, especially in younger patients if intercurrent infections are absent. The worst prognosis is usually observed in patients who are older with severe intercurrent illnesses, eg, myocardial infarction, sepsis, or pneumonia, especially when they are treated outside an ICU.
  • The presence of deep coma at the time of diagnosis, hypothermia, and oliguria are signs of poor prognosis.

Patient Education

  • Educate patients in the prevention of diabetic ketoacidosis so that a recurrent episode can be avoided.
  • Promotion of self-management and dealing with the stress of intercurrent illness always is part of the education process for adult patients with diabetes.9,10
  • For excellent patient education resources, visit eMedicine's Diabetes Center. Also, see eMedicine's patient education article, Diabetic Ketoacidosis.

Miscellaneous

Medicolegal Pitfalls

  • Failure to diagnose diabetic ketoacidosis (DKA) in the absence of a urinary test result that is positive for ketones
  • False belief that DKA is worsening based on positive results of a urine test for ketones, while, in fact, DKA is improving with return of predominate ketones from beta hydroxybutyrate to acetoacetate
  • Failure to recognize associated conditions, eg, myocardial infarction, UTI, pneumonia, perinephric abscess, or hidden sepsis
  • Failure to recognize signs and symptoms of cerebral edema
  • Rapid correction of hyperglycemia in the first 4-5 hours
  • Rapid correction of metabolic acidosis with sodium bicarbonate before correction of fluid loss
  • Stopping monitoring of serum potassium after it returns to the reference range
  • Infusing potassium chloride without continuous monitoring of serum potassium or ECG
 


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

  1. Mrozik LT, Yung M. Hyperchloraemic metabolic acidosis slows recovery in children with diabetic ketoacidosis: a retrospective audit. Aust Crit Care. Jun 26 2009;[Medline].

  2. Bradley P, Tobias JD. An evaluation of the outside therapy of diabetic ketoacidosis in pediatric patients. Am J Ther. Nov-Dec 2008;15(6):516-9. [Medline].

  3. Zargar AH, Wani AI, Masoodi SR, et al. Causes of mortality in diabetes mellitus: data from a tertiary teaching hospital in India. Postgrad Med J. May 2009;85(1003):227-32. [Medline].

  4. Lin SF, Lin JD, Huang YY. Diabetic ketoacidosis: comparisons of patient characteristics, clinical presentations and outcomes today and 20 years ago. Chang Gung Med J. Jan 2005;28(1):24-30. [Medline].

  5. Glaser NS, Marcin JP, Wootton-Gorges SL, et al. Correlation of clinical and biochemical findings with diabetic ketoacidosis-related cerebral edema in children using magnetic resonance diffusion-weighted imaging. J Pediatr. Jun 25 2008;[Medline].

  6. Bowden SA, Duck MM, Hoffman RP. Young children (<5 yr) and adolescents (>12 yr) with type 1 diabetes mellitus have low rate of partial remission: diabetic ketoacidosis is an important risk factor. Pediatr Diabetes. Jun 2008;9(3 Pt 1):197-201. [Medline].

  7. Potenza M, Via MA, Yanagisawa RT. Excess thyroid hormone and carbohydrate metabolism. Endocr Pract. May-Jun 2009;15(3):254-62. [Medline].

  8. Umpierrez GE, Jones S, Smiley D, et al. Insulin analogs versus human insulin in the treatment of patients with diabetic ketoacidosis: a randomized controlled trial. Diabetes Care. Jul 2009;32(7):1164-9. [Medline].

  9. Pugliese G, Zanuso S, Alessi E, et al. Self glucose monitoring and physical exercise in diabetes. Diabetes Metab Res Rev. Sep 2009;25 Suppl 1:S11-7. [Medline].

  10. Weber C, Kocher S, Neeser K, et al. Prevention of diabetic ketoacidosis and self-monitoring of ketone bodies: an overview. Curr Med Res Opin. May 2009;25(5):1197-207. [Medline].

  11. Ai D, Roper TA, Riley JA. Diabetic ketoacidosis and clozapine. Postgrad Med J. Aug 1998;74(874):493-4. [Medline].

  12. Amemiya S. Constant infused glucose regimen during the recovery phase of diabetic ketoacidosis in children and adolescents with IDDM. Diabetes Care. Apr 1998;21(4):676-7. [Medline].

  13. Bohan JS. Chemical measurements in ketoacidosis. Arch Intern Med. Sep 27 1999;159(17):2089. [Medline].

  14. Brandenburg MA, Dire DJ. Comparison of arterial and venous blood gas values in the initial emergency department evaluation of patients with diabetic ketoacidosis. Ann Emerg Med. Apr 1998;31(4):459-65. [Medline].

  15. Brink SJ. Diabetic ketoacidosis: prevention, treatment and complications in children and adolescents. Diabetes Nutr Metab. Apr 1999;12(2):122-35. [Medline].

  16. Carroll MA, Yeomans ER. Diabetic ketoacidosis in pregnancy. Crit Care Med. Oct 2005;33(10 Suppl):S347-53. [Medline].

  17. Catalano C, Fabbian F, Di Landro D. Acute pulmonary oedema occurring in association with diabetic ketoacidosis in a diabetic patient with chronic renal failure. Nephrol Dial Transplant. Feb 1998;13(2):491-2. [Medline].

  18. [Best Evidence] Della Manna T, Steinmetz L, Campos PR, Farhat SC, Schvartsman C, Kuperman H. Subcutaneous use of a fast-acting insulin analog: an alternative treatment for pediatric patients with diabetic ketoacidosis. Diabetes Care. Aug 2005;28(8):1856-61. [Medline].

  19. Edge JA, Ford-Adams ME, Dunger DB. Causes of death in children with insulin dependent diabetes 1990-96. Arch Dis Child. Oct 1999;81(4):318-23. [Medline].

  20. Fisken RA. Severe diabetic ketoacidosis: the need for large doses of insulin. Diabet Med. Apr 1999;16(4):347-50. [Medline].

  21. Hjort U, Christensen JH. Diabetic ketoacidosis and compliance. Lancet. Feb 28 1998;351(9103):674-5. [Medline].

  22. Hoffman WH, Locksmith JP, Burton EM, et al. Interstitial pulmonary edema in children and adolescents with diabetic ketoacidosis. J Diabetes Complications. 12(6):314-20. [Medline].

  23. Kannan CR. Bicarbonate therapy in the management of severe diabetic ketoacidosis. Crit Care Med. Dec 1999;27(12):2833-4. [Medline].

  24. Kaufman FR, Halvorson M. The treatment and prevention of diabetic ketoacidosis in children and adolescents with type I diabetes mellitus. Pediatr Ann. Sep 1999;28(9):576-82. [Medline].

  25. Kaufman FR, Halvorson M, Fisher L, Pitukcheewanont P. Insulin pump therapy in type 1 pediatric patients. J Pediatr Endocrinol Metab. 1999;12 Suppl 3:759-64. [Medline].

  26. Laffel L. Ketone bodies: a review of physiology, pathophysiology and application of monitoring to diabetes. Diabetes Metab Res Rev. Nov-Dec 1999;15(6):412-26. [Medline].

  27. Liss DS, Waller DA, Kennard BD, McIntire D, Capra P, Stephens J. Psychiatric illness and family support in children and adolescents with diabetic ketoacidosis: a controlled study. J Am Acad Child Adolesc Psychiatry. May 1998;37(5):536-44. [Medline].

  28. Mahoney CP, Vlcek BW, DelAguila M. Risk factors for developing brain herniation during diabetic ketoacidosis. Pediatr Neurol. Oct 1999;21(4):721-7. [Medline].

  29. Martin SL, Hoffman WH, Marcus DM, Passmore GG, Dalton RR. Retinal vascular integrity following correction of diabetic ketoacidosis in children and adolescents. J Diabetes Complications. Jul-Aug 2005;19(4):233-7. [Medline].

  30. Moller N, Foss AC, Gravholt CH, Mortensen UM, Poulsen SH, Mogensen CE. Myocardial injury with biomarker elevation in diabetic ketoacidosis. J Diabetes Complications. Nov-Dec 2005;19(6):361-3. [Medline].

  31. Paton RC, Sathiavageeswaran M. Severe diabetic ketoacidosis. Diabet Med. Oct 1999;16(10):884. [Medline].

  32. Reichel A, Rietzsch H, Kohler HJ, Pfutzner A, Gudat U, Schulze J. Cessation of insulin infusion at night-time during CSII-therapy: comparison of regular human insulin and insulin lispro. Exp Clin Endocrinol Diabetes. 1998;106(3):168-72. [Medline].

  33. Smith CP, Firth D, Bennett S, Howard C, Chisholm P. Ketoacidosis occurring in newly diagnosed and established diabetic children. Acta Paediatr. May 1998;87(5):537-41. [Medline].

  34. Timmons JA, Myer P, Maturen A, et al. Use of beta-hydroxybutyric acid levels in the emergency department. Am J Ther. May 1998;5(3):159-63. [Medline].

  35. Viallon A, Zeni F, Lafond P, et al. Does bicarbonate therapy improve the management of severe diabetic ketoacidosis?. Crit Care Med. Dec 1999;27(12):2690-3. [Medline].

  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].

  38. Younis N, Austin MJ, Casson IF. A respiratory complication of diabetic ketoacidosis. Postgrad Med J. Dec 1999;75(890):753-4. [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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