The specificity of a positive measurement of urinary ketones is low, so a positive urinary measurement of ketones doesn't establish a diagnosis of DKA.( 32771260, 10459090) False negatives may occur in patients with highly acidic urine. This test has a high sensitivity for DKA (98-99%), with urinary ketones are generally being ≧2+.The urinary ketone dipstick tests for acetoacetate.Therefore, an elevated anion gap does not necessarily imply DKA! This is especially true among patients with chronic renal failure, who may have a chronically elevated anion gap. Anion gap may be elevated due to a variety of causes (with the differential diagnosis explored here).Don't make this unnecessarily complicated. Please don't correct for albumin, glucose, or potassium.Using this formula, an elevated anion gap is above 10-12 mEq/L.Three ways to evaluate for ketoacidosis (#1) anion gap (Na – Cl – 10) 18 mM, to expedite discontinuation of the insulin infusion in a timely fashion.Anion gap is falling, but bicarbonate is not rising appropriately.NAGMA often emerges during the course of a DKA resuscitation.Management of non-anion-gap metabolic acidosis ( more) Most patients: provide their entire daily requirement of basal insulin.New diagnosis of diabetes: start 0.25 U/kg glargine.Patients should receive their full daily requirement of basal, long-acting insulin as a single dose of glargine:.Start basal insulin early (well before the anion gap has closed).Patient received full dose of basal insulin >2 hours previously. ![]() 2nd: Infuse LR at ~150-200 ml/hr, until glucose 5.3 mM, if renal function preserved.1st: Bolus with lactated Ringers (LR) if substantial volume depletion (which is usually the case).If the cause of DKA is unclear: blood cultures +/- urine culture, chest X-ray, perhaps CT abdomen/pelvis to evaluate for septic focus, possibly lipase (noting that DKA itself can increase lipase 14578269), troponin if genuine suspicion for ischemia.If unclear whether patient has DKA: beta-hydroxybutyrate & lactate levels.Minimum evaluation for a patient with DKA: Electrolytes including Ca/Mg/Phos, complete blood count with differential, urinalysis, EKG, pregnancy test as appropriate. ![]() ![]() DKA management checklist ✅ diagnostic evaluation ( more)
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