When intravenous access is unavailable, studies have found that giving the entire initial dose intramuscularly also is effective. Whole body potassium deficits typically are 3 to 5 mEq per L 3 to 5 mmol per L. Acidosis increases potassium levels and glucose administered with insulin lowers them.

Before treatment of DKA, the level of potassium usually is normal or elevated. Potassium should be started as soon as adequate urine output is confirmed and the potassium level is less than 5 mEq per L.

If the potassium level is less than 3. Studies of patients with a pH level of 6. Because there are no studies on patients with a pH level below 6. Bicarbonate therapy lowers potassium levels; therefore, potassium needs to be monitored carefully. Although the phosphate level frequently is low in patients with DKA, good-quality studies have shown that routine phosphate replacement does not improve outcomes in DKA, and excessive replacement can lead to hypocalcemia.

A serum deficit of 1 to 2 mEq per L 0. In addition to alterations in magnesium metabolism from DKA, many patients with diabetes have taken medications such as diuretics that also may lower magnesium levels.

Symptoms of magnesium deficiency are difficult to recognize and overlap with symptoms caused by deficiencies of calcium, potassium, and sodium. Paresthesias, tremor, carpopedal spasm, agitation, seizures, and cardiac dysrhythmias all are reported symptoms. Checking magnesium levels and correcting low levels should be considered in patients with DKA.

Patients usually are symptomatic at serum levels of 1. Whole body sodium deficits typically are 7 to 10 mEq per L 7 to 10 mmol per L. Serum sodium is falsely lowered by 1.

Hyponatremia needs to be corrected only when the sodium level is still low after adjusting for this effect. For example, in a patient with a serum glucose concentration of mg per dL A high serum sodium level almost always indicates hypernatremic dehydration.

Common complications of DKA include hypoglycemia, hypokalemia, and recurrent hyperglycemia. These may be minimized by careful monitoring. Hyperchloremia is a common but transient finding that usually requires no special treatment. Cerebral edema is a rare but important complication of DKA.

Although it can affect adults, it is more common in young patients, occurring in 0. Papilledema, hypertension, hyperpyrexia, and diabetes insipidus also may occur. Patients typically improve mentally with initial treatment of DKA, but then suddenly worsen.

Dilated ventricles may be found on CT or magnetic resonance imaging. Treatment of suspected cerebral edema should not be delayed for these tests to be completed.

In more severe cases, seizures, pupillary changes, and respiratory arrest with brain-stem herniation may occur. Once severe symptoms occur, the mortality rate is greater than 70 percent, and only about 10 percent of patients recover without sequelae.

Avoiding overhydration and limiting the rate at which the blood glucose level drops may reduce the chance of cerebral edema. About 10 percent of the patients initially diagnosed with cerebral edema have other intracranial pathology such as subarachnoid hemorrhage. The main differences in the management of children and adolescents compared with adults are the greater care in administering electrolytes, fluids, and insulin based on the weight of the patient and increased concern about high fluid rates inducing cerebral edema.

A flowchart for the management of DKA in children and adolescents from the ADA guideline is shown in Figure 2. Although DKA is less common in these patients than among those with type 1 diabetes, it does occur.

C-peptide levels may be helpful for determining the type of diabetes and guiding subsequent treatment. Risk factors for adolescent type 2 diabetes are hypertension and acanthosis nigricans.

Older patients are less likely to be on insulin before developing DKA, less likely to have had a previous episode of DKA, typically require more insulin to treat the DKA, have a longer length of hospital stay, and have a higher mortality rate 22 percent for those 65 years and older versus 2 percent for those younger than 65 years.

A blood glucose concentration of less than mg per dL, a bicarbonate level of 18 mEq per L or greater, and a venous pH level of greater than 7. Intravenous insulin should continue for one to two hours after initiation of subcutaneous insulin.

For patients who are unable to eat, intravenous insulin may be continued to maintain the blood glucose in a target range i. Prevention of another episode should be part of the treatment of DKA. Most patients with DKA will need lifetime insulin therapy after discharge from the hospital.

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Elevated ketones are a sign of DKA, which is a medical emergency and needs to be treated immediately. Your treatment will likely include:. DSMES services are a vital tool to help you manage and live well with diabetes while protecting your health. Skip directly to site content Skip directly to search.

Español Other Languages. Diabetic Ketoacidosis. Español Spanish Print. Minus Related Pages. High ketones? Call your doctor ASAP. Your breath smells fruity. You have multiple signs and symptoms of DKA. Your treatment will likely include: Replacing fluids you lost through frequent urination and to help dilute excess sugar in your blood.

Replacing electrolytes minerals in your body that help your nerves, muscles, heart, and brain work the way they should.

Too little insulin can lower your electrolyte levels. Receiving insulin. Insulin reverses the conditions that cause DKA. Taking medicines for any underlying illness that caused DKA, such as antibiotics for an infection.

Keep your blood sugar levels in your target range as much as possible. Take medicines as prescribed, even if you feel fine. Learn More. Learn About DSMES Living With Diabetes 4 Ways To Take Insulin Low Blood Sugar Hypoglycemia.