Diabetes ketoacidosis-related deaths are usually the result of the following: a triad of DKA symptoms (hyperglycemia, hyperketonemia, and metabolic acidosis), another underlying comorbid condition (eg, myocardial infarction, sepsis, acute respiratory distress syndrome), or the release of biological markers (ie, catecholamines).14,15,17 Thus, as previously stated, the management of potassium levels is important as both hyperkalemia and hypokalemia can lead to fatal arrthythmias.15
Direct mortality from DKA has dropped significantly over the past 20 years, from 8% to less than 1%.6 The US Centers for Disease Control and Prevention has observed a downward trend in death and estimates that 2,417 patients died in 2009 due to DKA,18 and recent postmortem studies have revealed new insights into DKA-related deaths.19 Blood and vitreous acetone concentrations are strong indicators for predeath hyperglycemia and ketosis (if there are no underlying comorbid and/or pharmacological provocations). Blood acetone levels greater than 0.01 g/dL antemortem are suggestive of DKA. It is recommended that these tests should be performed in sudden deaths which have no biological or anatomical cause of death. Postmortem diagnosis of DKA is made with the following criteria: history of DM, increased vitreous glucose concentrations, and elevated blood/vitreous/urine acetone concentrations (>200 mg/dL). If results of the abovementioned parameters are inconclusive, measurement of lactic acid postmortem is thought to further support a diagnosis of DKA.19
Patient Counseling and Education
Approximately 33% of patients whose death was associated with DKA had no personal history of DM.19 This statistic emphasizes the importance of taking a thorough history, physical examination, blood glucose evaluation, and educating patients about the signs and symptoms of DM and DKA.
Patient counseling and education are important, especially in patients whose racial/ethnic background places them at increased risk of developing DM (eg, patients of black or African American, American Indian, Alaskan Native, Asian American, Hispanic, Native Hawaiian, or Pacific Islander descent).20,21 Strategies for preventive management include advocating regular glucose monitoring as well as dietary and lifestyle modifications. In patients with DM, successful management of the condition and its comorbidities can help prevent DKA and associated mortality.
Conclusion
As this case demonstrates, despite prompt diagnosis and management, patients with DKA—especially those with uncontrolled, undiagnosed, or advanced DM—are associated with fatal outcomes. In many cases, however, DKA can be successfully managed and reversed, especially when the condition is recognized early. Management includes not only IV therapy to adjust fluid and insulin levels, but also restoring electrolyte balance (especially potassium and bicarbonate). Frequent and careful evaluation of laboratory values is vital to the successful treatment of DKA, as there are numerous pitfalls and complications that the emergency physician can encounter. Patients who either have or are at an increased risk of developing DM or DKA may benefit from preventive measures, including regular glucose monitoring and appropriate diet and lifestyle modifications.
Mr Hassan-Ali is a fourth-year medical student at Windsor University School of Medicine, St Kitts, West Indies. Dr Raziuddin is an internist and an emergency medicine physician at Weiss Memorial, Thorek Memorial, and Westlake Hospitals, Chicago, Illinois.