European Journal of Internal Medicine xxx (xxxx) xxx

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European Journal of Internal Medicine

journal homepage: www.elsevier.com/locate/ejim

Review Article

Management of diabetic ketoacidosis

Leonid Barski a, *, Evgeny Golbets a, Alan Jotkowitz b, Dan Schwarzfuchs c
a
Department of Internal Medicine F, Soroka Univerity Medical Center, P.O.Box 151, Beer–Sheva 84101, Israel
b
Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel
c
Department of Emergency Medicine, Soroka University Medical Center, Beer–Sheva, Israel

A R T I C L E I N F O A B S T R A C T

Keywords: Diabetic ketoacidosis (DKA) is an acute life-threatening emergency in patients with diabetes, it can result in
Diabetic ketoacidosis serious morbidity and mortality. Management of DKA requires reversing metabolic derangements, correcting
Management of DKA volume depletion, electrolyte imbalances and acidosis while concurrently treating the precipitating illness.
DKA treatment
There are still controversies regarding certain aspects of DKA management. Different society guidelines have
inconsistencies in their recommendations, while some aspects of treatment are not precise enough or have not
been thoroughly studied. These controversies may include issues such as optimal fluid resuscitation, rate and
type of Insulin therapy, potassium and bicarbonate replacement. Many institutions follow common society
guidelines, however, other institutions either develop their own protocols for internal use or do not routinely use
any protocols, resulting in inconsistencies in treatment and increased risk of complications and suboptimal
outcomes. The objectives of this article are to review knowledge gaps and controversies in the treatment of DKA
and provide our perspective on these issues.
Moreover, we believe that special patient factors and comorbidities should receive more careful attention and
consideration. Factors like pregnancy, renal disease, congestive heart failure, acute coronary syndrome, older
age, use of sodium-glucose cotransporter-2 (SGLT2) inhibitors and site of care all impact the treatment approach
and require tailored management strategies.
However, guidelines often lack sufficient recommendations regarding specific conditions and comorbidities,
we aim to address unique circumstances and provide an approach to managing complex patients with specific
conditions and co-morbidities. We also sought to examine changes and trends in the treatment of DKA, illuminate
on aspects of latest research with a perspective towards future developments and modifications.

1. Introduction life-threatening iatrogenic complications such as hyper/hypokalemia,

hypoglycemia, cerebral edema, and cardiac arrhythmias.
Diabetic ketoacidosis (DKA) is an acute life-threatening emergency DKA occurs most often in patients with type 1 diabetes; however
in patients with diabetes, characterized by hyperglycemia, metabolic patients with type 2 diabetes are also susceptible to DKA under stressful
acidosis and ketonemia, it can result in serious morbidity and mortality conditions. Severity of presentation and DKA duration are similar in
[1]. Management of DKA requires reversing metabolic derangements by both type 1 and type 2 diabetes, suggesting that the same clinical
correcting volume depletion and electrolyte imbalances and adminis­ management protocol is equally effective, however patients with type 2
tering insulin to correct acidosis while concurrently treating the diabetes have longer hospital stays [2,3].
precipitating illness [1]. Suboptimal management may lead to Although mortality rates for diabetic ketoacidosis (DKA) have been

Abbreviations: DKA, diabetic ketoacidosis; ADA, The American Diabetes Association; EASD, European Association for the Study of Diabetes; BES, balanced
electrolyte solutions; normal saline, 0.9% sodium chloride; RL, ringer lactate; CII, continuous insulin infusion; RII, regular insulin infusion; ICU, intensive care unit;
GM, Glucommander™; EMR, electronic medical record; BG, blood glucose; FAIAs, fast-acting insulin analogues; LAI, long-acting insulins; LOS, length of stay; ED,
Emergency Departments; HDU, high dependency unit; HF, heart failure; ACS, acute coronary syndrome; SGLT2, sodium-glucose cotransporter-2; ACE, angiotensin-
converting enzyme; ARB, angiotensin receptor blocker; GLP-1, glucagon-like peptide-1; AKI, acute kidney injury; ESKD, end-stage renal disease; HbA1C, hemoglobin
A1C (glycated hemoglobin).
* Corresponding author.
E-mail address: [email protected] (L. Barski).

https://doi.org/10.1016/j.ejim.2023.07.005
Received 27 April 2023; Received in revised form 27 June 2023; Accepted 3 July 2023
0953-6205/© 2023 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

Please cite this article as: Leonid Barski et al., European Journal of Internal Medicine, https://doi.org/10.1016/j.ejim.2023.07.005
L. Barski et al. European Journal of Internal Medicine xxx (xxxx) xxx

steadily declining in the USA with a current in-hospital fatality rate of mOsm/L), lower pH (5.5 vs RL 6.6), and a higher chloride concentration
0.4%, trends have shown that DKA hospitalization rates have dramati­ (154 mEq/L vs RL 109 mEq/L), which often associates with the devel­
cally increased by 54.9% which reflects a significant healthcare burden opment of hyperchloremic metabolic acidosis [4–6,12,16–19].
[4]. Several small studies of adults with DKA revealed that fluid admin­
There are still controversies regarding several aspects of DKA man­ istration of BES was associated with faster resolution of DKA compared
agement [4–6]. Many institutions follow common guidelines such as The to normal saline. The authors concluded that these results suggest that
American Diabetes Association (ADA), the European Association for the BES may be preferred for acute management of DKA [4,20].
Study of Diabetes (EASD), updated guidelines from the Joint British Balanced electrolyte solutions are more expensive than normal saline
Diabetes Society for Inpatient Care. However, other institutions either and have several potential adverse effects. For example, the buffers
develop their own protocols for internal use or do not routinely use any present in these solutions are converted to bicarbonate upon infusion,
protocols, resulting in inconsistencies in treatment, risk for suboptimal which can lead to metabolic alkalosis [14,20,21]. The infusion of
treatment and thus an increased risk of complications and mortality Ringer’s lactate may also cause elevations in potassium and lactate
[5–11]. serum levels, with a greater concern for the latter in patients with liver
The objectives of this article are to review knowledge gaps and failure [14,22–24]. The lactate may be converted to glucose which may
controversies in the treatment of DKA and provide our perspective on exacerbate hyperglycemia [14,24], while acetate has been associated
these issues. We also sought to examine changes and trends in the with altered myocardial activity and impaired hemodynamics [14,25].
treatment of DKA with a perspective on future developments. Finally, administration of large volume crystalloid fluids that are more
With the extension of life expectancy and improvements in diagnosis hypotonic in comparison to normal saline may increase the risk of ce­
and treatment many patients present with unique conditions and rebral edema, especially relevant in pediatric and elderly patients [14,
comorbidities, which necessitate special attention to specific clinical 26].
factors and treatment modification. However, guidelines often lack Thus, the question of crystalloid fluid choice in patients with DKA
sufficient recommendations regarding specific conditions and comor­ remains open. The clinician ought to weigh the association between
bidities. Factors like pregnancy, renal disease, congestive heart failure, normal saline and the development of hyperchloremic metabolic
acute coronary syndrome, older age, use of sodium-glucose cotrans­ acidosis, as well as the possibility of kidney injury, with the potential
porter-2 (SGLT2) inhibitors and site of care all impact treatment and side effects of BES and the limited data and experience supporting their
require tailored management strategies. We aim to address these unique use a should also to be considered.
circumstances and provide an approach to managing complex patients We believe that the selection of crystalloids for fluid resuscitation
with specific conditions and co-morbidities. should be personalized based on the patient’s individual characteristics,
such as clinical and laboratory data and comorbidities. Future ran­
2. Fluid resuscitation domized controlled trials are needed to make better evidence-based
recommendations, but in our opinion, the more favorable physiolog­
Along with insulin therapy, intravenous fluid administration to ical characteristics of BES are likely to lead to its wider acceptance and
expand intravascular, interstitial, and intracellular volume is a key use.
component of the acute management of DKA [7–10].
Current guidelines suggest the use of 0.9% sodium chloride solution 3. Insulin therapy
(normal saline) as the preferred resuscitation fluid in the management of
DKA [5–7,9,10]. However, balanced electrolyte solutions (BES) have Insulin therapy is a crucial component of DKA management as it
been proposed as an alternative due to a lower propensity to cause reduces hepatic gluconeogenesis and suppresses ketogenesis [27].
hyperchloremic metabolic acidosis [4,12]. The American Diabetes As­ Continuous insulin infusion (CII) is historically recommended and
sociation (ADA) guidelines recommends initial treatment with 1.0–1.5 L widely accepted as standard of care for the treatment of DKA [7,9,10].
of normal saline over one hour, followed by continuous infusion with Intravenous regular insulin infusion (RII) has a rapid (15 min) onset of
either normal saline or 0.45% saline depending on serum sodium con­ action and allows for titratable drug administration to match changing
centration [7]. Similarly, Diabetes Canada recommends initial volume glucose levels [10]. Insulin rates approximating 0.1 unit/kg/h, are
resuscitation with NS and suggests varying rates of infusion tailored to recommended during this initial stage of management by various in­
the volume deficit [10]. The guidelines created by the Joint British ternational guidelines [5–7,9,10]. Treatment usually resolves hyper­
Diabetes Societies Inpatient Care Group acknowledge the paucity of glycemia before acidosis; however, continued ketoacid suppression
evidence for the use of one type of fluid over another and include a requires a careful balance of insulin and dextrose infusions to prevent
statement that balanced electrolyte solutions (BES) can be used. None­ hypoglycemia. However relatively little attention has been given by
theless, they recommend the use of normal saline in the acute man­ international guidelines who offer conflicting recommendations [5,6].
agement of DKA, given the degree of historical experience with its The insulin rate reduction to 0.05 unit/kg/h when initiating dextrose
administration [5,6,13]. was the ‘most important’ protective factor against hypoglycemia,
In recent years, much attention has focused on selecting the appro­ though no data were provided to support it [5,6,28]. This rate reduction
priate crystalloid fluid for acute resuscitation purposes [14]. Normal is not associated with a delay in resolution of anion gap acidosis, an
saline, composed of equal concentrations of sodium and chloride, is an excess of rebound hyperglycemia or a prolongation of intensive care unit
inexpensive and commonly used fluid in the acute setting. However, the (ICU) stay [28]. The incidence of hypoglycemia due to intravenous in­
chloride concentration in normal saline (154 mmol/L) is higher than sulin in DKA treatment has not been well studied, but 35% incidence of
that in human plasma (94–111 mmol/L), which can cause a non-anion hypoglycemia was described with standard care of intravenous RII [28].
gap hyperchloremic metabolic acidosis, especially when administered Insulin use causing hypoglycemia or spontaneous hypoglycemia are
in large volumes [15–19]. Moreover, accumulating evidence suggests associated with increased mortality among hospitalized patients [29,
that normal saline may increase the risk of acute kidney injury thus 30].
impairing patient recovery [14,15,20]. Several options are available for improving the use intravenous in­
BES, including Ringer lactate (RL) and Plasma-Lyte A (Baxter Inc), sulin therapy for patients with DKA. One of these is computer-based
are isotonic crystalloids that have more similar composition to human algorithms of CII. It is not known, however, if computer-based algo­
plasma. In addition to sodium chloride, BES contains potassium, cal­ rithms are superior to standard protocols. Furthermore, there are no
cium, and lactate. Although normal saline and BES are both considered intravenous protocols that have been specifically validated for the
isotonic, the former has a higher osmolality (308 mOsm/L vs LR 273 treatment of DKA and guidelines do not allude to using a specific

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protocol over another. In a one retrospective study, authors compare a anion gap > 12, and altered mental status) carry an ominous prognosis
computer decision support system (Glucommander™ (GM)) for insulin [41]. The acid-base status has received great attention, due to the po­
dosing, versus conventional protocol. Glucommander™ (GM) is a soft­ tential of bicarbonate-based therapy, however it’s use remains
ware that uses algorithms to provide dosing recommendations for controversial.
intravenous and subcutaneous insulin. It takes into account clinical Severe acidemia has been associated with impaired hemodynamics,
variables and integrates with electronic medical record (EMR) systems. including vasodilation, and decreased cardiac output in animal studies
The GM therapy group was associated with a lower hypoglycemia [41]. Studies involving large case series of patients with severe DKA,
rate with a faster normalization of bicarbonate levels. The initial blood showed little differences were found in clinical outcomes when
glucose (BG) was significantly higher in the GM group but the time for considering the degree of acidosis as an isolated variable [41,42]. In one
resolution of DKA was faster with GM [31]. We expect to see more de­ study that included 18 patients with severe DKA, the rapid recovery that
cision support systems used in the future; their efficaciousness will need characterized these patients, regardless of whether they received bi­
to be demonstrated through prospective trials. In our opinion, such carbonate therapy, provides additional support for the idea that the
systems have the potential to reduce complications, help medical teams, degree of acidosis does not determine the outcome of DKA. The authors
and minimize healthcare costs. suggest that the severity of acidemia may influence mortality in children
In the past two decades, fast-acting insulin analogues (FAIAs): in­ with type 1 diabetes, but this does not appear to be the case in adults
sulin lispro, insulin aspart, insulin glulisine and fast-acting insulin aspart with type 2 diabetes and concluded that hydration state or sepsis are
(faster aspart), have been developed. Subcutaneous administration of more important to hemodynamics than the severity of acidemia [41].
these FAIAs has an onset of action of ≈5–15 min, a peak action of 1–3 h Although, use of intravenous bicarbonate may be considered for
and duration of action of 3–5 h [32]. These pharmacological properties patients with a pH less than 6.9 according to the ADA, the impact of this
suggest that subcutaneous FAIAs may produce clinical benefits compa­ therapy is unclear [7,27]. In one study adult patients with severe DKA
rable with intravenous RII in DKA and may be useful to manage some and initial pH less than 7.0, were stratified into two groups based on
DKA cases outside the ICU [6,33,35]. Previous investigations comparing receipt of intravenous bicarbonate. The authors observed no significant
the effects of subcutaneous FAIAs versus intravenous RII for treating difference in time to resolution of acidosis or time to hospital discharge
mild-to-moderate DKA are inconclusive [33,35]. Subcutaneous between patients who received intravenous bicarbonate compared with
long-acting insulins (LAI): insulin glargine, insulin detemir and insulin those who did not. There was no significant difference in hours of
degludec, provides a basal insulin component, and its concomitant continuous insulin infusion or potassium requirements [43].
administration with intravenous RII in DKA accelerates ketoacidosis Owing to the possible harm and lack of evidence for clinical benefit,
resolution and prevents rebound hyperglycaemia, especially during the use of bicarbonate should be discouraged and limited to rare and
transition from intravenous RII to subcutaneous insulin. Early insulin critical cases when the pH is below 6.9.
glargine use in DKA was safe and associated with a trend towards faster
DKA resolution and a shorter length of stay (LOS) [6,33,34,36,37]. In a 6. Special considerations
recent large retrospective pre- and post- cohort study (n = 7989),
combination therapy with subcutaneous insulin lispro and subcutaneous 6.1. Site of treatment and hospitalization. Management of patients with
insulin glargine reduced rates of ICU admission and 30-day hospital DKA outside of the intensive care (ICU) unit
readmission with no increase in hypoglycemia or 30-day mortality rates
when compared with intravenous RII [38]. The use of subcutaneous DKA is a life-threatening state; hence, it is essential that patients are
FAIAs in the treatment of DKA can be safe, provided that there is managed in the most appropriate setting. To meet this goal, scientific
appropriate patient selection. Potential candidates include those who societies worldwide have developed recommendations and step-by-step
are alert, have few or no comorbidities and are diagnosed with mild to algorithms for DKA treatment. Emergency Departments (EDs) are typi­
moderate DKA. Factors that affect absorption into the bloodstream, cally the initial site of diagnosis, treatment initiation and stabilization.
including obesity, the use of vasoconstricting drugs, and blood pressure, When possible, intubation should be avoided in the DKA patients.
are important to consider in identifying the right patients. Currently, However, the comatose DKA patient, especially if vomiting, requires
there is an underutilization of this option that could potentially reduce intubation. In intubated DKA patients, maintenance of hyperventilation
complications and healthcare costs. is important for prevention of worsening of acidosis.
In general, it is recommended that DKA will be treated with intra­
4. Potassium replacement venous RII in the ICU or high dependency unit (HDU). The treatment
requires intensive monitoring of vital signs, frequent blood tests, use of
Patients with DKA usually present with significant potassium defi­ intravenous insulin with increased risk of life-threatening complications
ciency. It is caused by osmotic diuresis, excretion of potassium ketoacid (e.g., severe electrolyte disturbances, pulmonary edema, cerebral coma)
anion salts, secondary hyperaldosteronism, and gastrointestinal loss. [7,9,10,44,45]. The ICU and HDU are scarce and expensive resources
However, patients often present with normal or even elevated potassium that are often critically strained [46]. Thus, incorporating new man­
concentrations due to intracellular shift [39]. The current recommen­ agement strategies can enable emergency situations that were tradi­
dations of all guidelines determine the amount of potassium that should tionally treated in the ICU/HDU to be managed outside of these settings
be supplemented depending on blood potassium levels [5–7,9,10]. [33,47]. DKA has been identified as suitable for treatment in a
The administration of insulin stimulates the activity of Na+/K+- non-ICU/HDU setting if the right patient selection, appropriate treat­
ATPase, which results in active uptake of potassium by cells, leading to ment, and monitoring can be put in place [48,49].
intracellular shift of potassium and hypokalemia. During DKA treat­ It has been demonstrated that DKA patients can be safely treated in a
ment, the serum potassium level decreases rapidly and can result in life non-ICU environment, such as a general ward or an emergency
threatening complications, such as bradycardia, ventricular fibrillation, department [47,50]. In several trials, treatment of selected DKA patients
or acute respiratory failure [39,40]. Therefore, continuous monitoring in a non-ICU setting was not associated with increased mortality or
of blood potassium levels and adherence to potassium replacement longer time to DKA resolution and was found to be more cost effective
protocols is crucial [5–7,9,10,39]. when compared to patients treated in the ICU [47,50]. In low ICU
resource environments, an ICU physician prioritizes ICU bed allocation
5. Bicarbonate replacement based on the cases present in the medical center at any given time.
Previous studies conducted in ICU restricted environments have
Severe cases of DKA (pH ≤ 7.00, bicarbonate level ≤ 10.0 (mEq/L), demonstrated that both short and long-term survival rates were

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associated with ICU admission [47,50,51]. patients with elevated troponin and suspected ACS must undergo
Some medical centers have resources for intravenous RII and the comprehensive investigation with echocardiography and coronary
ability for monitoring patients with DKA in medical ward departments, stratification.
but other medical centers may successfully use subcutaneous FAIAs.
Furthermore, subcutaneous LAI provides a basal insulin component, and 6.3. Management of DKA in patients with type 2 diabetes treated with
its concomitant administration with intravenous RII accelerates ketoa­ sodium-glucose cotransporter-2 (SGLT2) inhibitors
cidosis resolution and prevents rebound hyperglycemia, thus may
facilitate treatment in non-ICU setting [33,34,47–49]. Sodium-glucose cotransporter-2 (SGLT2) inhibitors were approved
Therefore, in our opinion, in a setting of limited ICU capacity, DKA in 2013 for the treatment of adults with type 2 diabetes mellitus. They
treatment does not necessarily require admission to the ICU. Our pre­ have been shown to reduce the risk of myocardial infarction, cardio­
vious results highlight the importance of including step-down units vascular mortality, heart and renal failure [56].
when devising local protocols for care of these patients [47]. We believe In adults with type 2 diabetes, SGLT2 inhibitors were found to in­
that in the future, more patients will be able to receive treatment in crease the risk of DKA (and euglycemic DKA), in observational studies
general wards, in an ED setting or even through home care services with and randomized clinical trials [56]. In addition, patients with DKA and
remote monitoring. More prospective research is needed in this area, SGLT2 inhibitors treatment had longer time to resolution than type 1
with an emphasis on appropriate patient selection, with attention given diabetes patients. The mechanisms by which SGLT2 inhibitors are
not only to the severity of DKA but also to the triggers and underlying associated with ketoacidosis are not fully understood. It may be related
comorbidities. to the insulin-independent reduction of blood glucose through increased
urine glucose excretion, which allows for glycemic control with
6.2. Management of DKA in patients with CHF and ACS concomitant reduction in insulin requirement. Moreover, the potential
increase in glucagon secretion leads to a decrease in the
The impact of heart failure (HF) on management of patients with insulin-to-glucagon ratio and promotes ketogenesis [57,58].
DKA has limited data and no clear recommendations exist in current Placebo-controlled trials in type 1 diabetes have consistently shown
guidelines. Moreover, the dramatic nature of hospitalizations for DKA an increased risk of DKA associated with the use of SGLT2 inhibitors. As
can sometimes lead clinicians to overlook the potential influence of a a result, the FDA has not approved their use for the treatment of type 1
patient’s history of HF on the outcomes of their DKA episode [52]. It has diabetes [57,58].
been shown that a history of HF is associated with increased risks for Patients with a longstanding history of type 2 diabetes mellitus and
in-hospital mortality among patients admitted for DKA. Additionally, poor glucose control appear to have a higher susceptibility to develop­
such patients are more prone to experiencing extended LOS and have a ment of DKA, other risk factors include pancreatic insufficiency, alcohol
higher likelihood of being transferred to a nursing home or similar dependence and ketogenic diets [56,57,59]. It is therefore advisable to
short-term healthcare facilities [52]. Current guidelines for DKA provide avoid these medications until risk factors are appropriately addressed.
no specific recommendations on the management of patients with a To further minimize the risk of euglycemic DKA with SGLT2 inhibitors,
history of HF [7,9,10]. The standard approach to the management of it is advised to discontinue these drugs for at least three to five days
DKA includes vigorous hydration, insulin therapy and electrolyte before planned surgical procedures, during periods of acute illness, or
repletion. Carefully designed studies are needed to identify the risk prolonged fasting [59].The absence of excessive hyperglycemia can
factors and mechanisms that contribute to poor outcomes of HF related delay recognition of the problem by both the patients and the clinician.
hospitalizations of DKA. Knowledge of such factors could guide appro­ Blood gasses and ketones should be obtained in any patient with nausea,
priate strategies for optimization of care and improve outcomes. The vomiting, or malaise while taking SGLT2 inhibitors. Once diagnosed,
management of patients with medical history of HF that develop DKA management of euglycemic DKA is straightforward and similar to the
must be very careful, particularly with cautious and closely monitored management of DKA [60]. The mainstay of treatment involves rapid
fluid infusion. Excessive fluid load may cause decompensation of HF. In correction of dehydration using intravenous fluids and correction elec­
managing patients with HF who develop DKA one should consider trolyte abnormalities [60,61]. The second most important step in the
stopping or decreasing the dose of all medications that could harm the management is the use of an insulin drip along with a dextrose con­
patient’s status. For example, SGLT2 inhibitors, GLP-1 agonists, ACE taining solution until the anion gap, and bicarbonate levels normalize
inhibitors, ARBs, and diuretics. [62]. Increased glucose administration using higher percentages of
The deleterious impact of a history of HF on clinical outcomes of DKA dextrose (10% or 20%) are required to facilitate the concomitant
might extend to patients with subclinical HF as well. In future studies, it administration of the relatively large amounts of insulin that are needed
is important to explore this notion by analyzing biomarkers such as BNP to correct the severe acidosis in these patients [7,60,63].
along with echocardiographic data including bed side echocardiography
as predictors of clinical outcomes. Such data could assist in the risk 6.4. Management of DKA in pregnancy
stratification and development of management strategies for patients
with subclinical HF who are hospitalized for DKA. Until then, the The pathophysiology of DKA in pregnancy has its own characteris­
development of expert guidelines would be helpful to guide clinicians in tics. Pregnancy is characterized by insulin resistance, accelerated star­
the management of DKA in these patients. [52]. vation and respiratory alkalosis especially in the second and third
DKA is associated with an increased risk of subsequent major adverse trimesters [64]. The most important endocrine changes affecting insulin
cardiovascular events [53]. Myocardial infarction is a rare but resistance in pregnancy are increased levels of estrogen, progesterone,
well-known cause of diabetic decompensation. ACS and DKA are two cortisol and TNFα [64–66]. On the other hand, the gradual decline in
conditions that can trigger each other, and it is often difficult to know insulin sensitivity is considered to be a physiological mechanism helping
which condition appears first. The mortality rate is significantly greater to provide glucose to the fetus. Increased alveolar ventilation in preg­
for the DKA patients with elevated troponin compared with the patients nant women gives rise to a state of respiratory alkalosis that is overcome
with normal troponin levels [54]. In addition, the elevated troponin by means of an increased renal excretion of bicarbonate. These changes
level is a predictor of poor outcome in patients admitted to intensive can trigger the onset of ketoacidosis at lower glycemic levels compared
care for clinical conditions other than ACS [54]. Notwithstanding that to non-pregnant patient [60,64,66–68].
DKA is a known cause of troponin increase without ACS, it stands to DKA during pregnancy can be fatal for the fetus, with fetal demise
reason that a troponin elevation in a DKA patient should always be incidence ranging from 15% to 60%. Maternal ICU admission and higher
considered as an ACS until proven otherwise [53,55]. Therefore, all serum osmolality during the DKA event were associated with increased