Provide education regarding sick day management to patients with diabetes to prevent DKA.

Ensure that patients understand the need to continue insulin therapy.

Educate the public to recognize the signs and symptoms of diabetes mellitus.

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Screen all patients with moderate to severely elevated blood sugars (≥350 mg/dL).

Consider diabetic ketoacidosis in patients with an anion gap metabolic acidosis.

Consider DKA in diabetes mellitus patients with infection, CVA, MI, or other illness.

Consider DKA in diabetic patients with symptoms of nausea and vomiting, even if blood glucose is <250 mg/dL.

Consider DKA in patients on atypical antipsychotics who present with hyperglycemia.

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History and Physical Examination
Take a careful history for symptoms suggesting hyperglycemia or DKA.

Perform a physical exam looking for signs of elevated blood sugar and DKA.

Consider DKA in diabetic patients with neurologic impairment.

Consider DKA in patients with type 2 diabetes who are dehydrated, acidotic, or who have very high blood sugars.

Laboratory Tests
Consider DKA if hyperglycemia, acidosis, or ketonemia are present.

Differential Diagnosis
Consider a diagnosis other than DKA if there is no response to therapy.

Consider another diagnosis if blood glucose is <250 mg/dL.

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Begin rehydration for DKA immediately.

Begin insulin therapy when serum electrolytes are available.

Monitor potassium levels closely and replace potassium deficit in all patients with DKA.

Determine the need for bicarbonate therapy.

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Educate patients to recognize early signs of DKA.

Consider recurrent DKA to be a “red flag.”

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From the ACP Diabetes Care Guide

Persons with diabetes have a 2- to 4-fold higher hospitalization rate than do those without diabetes. Diabetes predisposes to a number of conditions that may lead to hospitalization, including coronary artery disease, cerebrovascular disease, peripheral vascular disease, nephropathy, and infection. Poorly controlled diabetes has been associated with increased infectious complications, delayed wound healing, increased medical costs, increased length of stay, and increased mortality.

The general goals for patients with diabetes in the acute care setting are:

• Avoiding hypoglycemia or hyperglycemia
• Avoiding metabolic abnormalities, such as volume depletion or electrolyte abnormalities
• Meeting nutritional needs
• Assessing educational needs

NOTE: You may order free copies of the complete ACP Diabetes Care Guide (book and CD-ROM).

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From the ACP Diabetes Care Guide

All persons involved in the care of persons with diabetes need to be able to determine when hospitalization is warranted. General hospital admission guidelines for diabetes are summarized (in this chapter). When counseling patients about hypoglycemia and hyperglycemia, emphasize that the best treatment is prevention: be proactive by recognizing the signs early, be prepared to treat, treat appropriately, and seek prompt attention when needed. It is always better to err on the side of safety.

NOTE: You may order free copies of the complete ACP Diabetes Care Guide (book and CD-ROM).

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Diabetic ketoacidosis (DKA) is the most life-threatening acute complication of diabetes, and is often the presenting manifestation of type 1 diabetes. In patients with established type 1 disease, DKA may occur during superimposed acute infections, such as influenza, pneumonia, or gastroenteritis, especially in patients who do not follow “sick day” rules; in patients on insulin pumps when insulin infusion is technically interrupted; or in patients who are noncompliant.

Noncompliance is generally a problem in teenagers and in substance abusers. In almost all cases, DKA is preventable by a well-educated patient who is compliant with glucose monitoring and understands the need for increased insulin doses during stress.

DKA may occur in patients with type 2 during severe medical stress such as with overwhelming infection or myocardial infarction.

The syndrome of DKA indicates profound insulin deficiency, in combination with excess circulating concentrations of counter-regulatory factors, especially glucagon. The major manifestations of DKA, hyperglycemia, ketosis, and dehydration, are directly or indirectly related to insulin deficiency.

Note: Subscription to MKSAP 14 is required to view this material. For more information, visit www.acponline.org.

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Several investigators have reported that more than half of African-American persons with new diagnoses of diabetic ketoacidosis have clinical, metabolic, and immunologic features of type 2 diabetes during follow-up. These patients are usually obese, have a strong family history of diabetes, have a low prevalence of autoimmune markers, and lack a genetic association with HLA. Their initial presentation is acute, with a few days to weeks of polyuria, polydipsia, and weight loss and lack of a precipitating cause of metabolic decompensation. At presentation, they have markedly impaired insulin secretion and insulin action, but intensified diabetic management results in significant improvement in β-cell function and insulin sensitivity sufficient to allow discontinuation of insulin therapy within a few months of follow-up. On discontinuation of insulin therapy, the period of near-normoglycemic remission may last for a few months to several years. The absence of autoimmune markers and the presence of measurable insulin secretion have proven useful in predicting near-normoglycemic remission and long-term insulin dependence in adult patients with a history of diabetic ketoacidosis. This clinical presentation is commonly reported in African and African-American persons but is also observed in Hispanic persons and those from other minority ethnic groups. The underlying mechanisms for β-cell dysfunction in ketosis-prone type 2 diabetes are not known; however, preliminary evidence suggests an increased susceptibility to glucose desensitization.

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