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TOPLINE:

Among patients in the emergency department (ED) who screened positive for diabetic ketoacidosis (DKA) or were diagnosed with the condition, just over half met laboratory criteria; however, nearly one third of those not meeting initial laboratory criteria were still diagnosed with DKA based on symptoms and clinical presentation, a retrospective study found.

METHODOLOGY:

• Researchers conducted a retrospective observational study at an urban academic ED from 2019 to 2023, including 1676 adults (median age, 47 years; 51.9% men; 74.0% Black individuals) with point-of-care (POC) glucose levels > 300 mg/dL and POC ketone levels > 1.1 mmol/L and/or an ED diagnosis of DKA.
• POC glucose levels > 300 mg/dL prompted ketone testing. DKA was defined as pH < 7.3 or bicarbonate levels ≤ 18 mmol/L; in patients without blood gas testing, it was defined as an anion gap > 15 mmol/L and CO2 levels ≤ 18 mmol/L.
• The primary outcomes were fulfillment of initial laboratory criteria for DKA, diagnosis of DKA despite not meeting these criteria, and identification of alternative diagnoses explaining hyperglycemia, ketosis, or acidosis.

TAKEAWAY:

• Overall, 53% of the patients met at least one laboratory criterion for DKA; among these, 88% met criteria based on pH and bicarbonate levels and 12% met criteria based on CO2 levels and anion gap. Overall, 87.3% of the patients received an ED diagnosis of DKA.
• Among 740 patients who screened positive on POC testing but whose initial laboratory results did not meet DKA criteria, 31% were diagnosed with DKA; only 7.4% of those with early DKA subsequently had laboratory findings meeting diagnostic criteria.
• Among patients screening positive on POC testing who did not meet laboratory criteria for DKA and were not diagnosed with the condition, common primary ED diagnoses included hyperglycemia (38% of patients), infection (13.1% of patients), starvation ketosis (11% of patients), and hyperosmotic hyperglycemic state (2.2% of patients).

IN PRACTICE:

"This study suggests that ED clinicians use criteria beyond laboratory values to diagnose DKA and support the premise that DKA is ultimately a clinical rather than a purely laboratory-diagnosed condition," the authors wrote.

SOURCE:

The study was led by Richard T. Griffey, Washington University School of Medicine in St. Louis, St. Louis, Missouri. It was published online on May 06, 2026, in Academic Emergency Medicine.

LIMITATIONS:

The study was limited by its retrospective design , reliance on electronic medical records and coded diagnoses, and limited insight into physician decision-making beyond laboratory values. The diagnoses assigned during ED visits or hospitalization may not have been confirmatory, and categorization of nondiabetic DKA diagnoses was based on coded data rather than direct chart or laboratory review. Documentation of diabetes type was inconsistent, and patients with euglycemic DKA related to SGLT2 inhibitors or GLP-1 receptor agonists were not included in the analysis.

DISCLOSURES:

The study was funded by the National Center for Advancing Translational Sciences. The authors reported having no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.