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Copyright (c) 2025 Musaad Ibrahim Saleh Altuwayjiri, Bandar Abdullah Alshalash, Khaled Ali Ahmed Shibli, Ali Hamed Ahmad Mahnashy, Abduh Ahmad Abduh Homadi, Jawahir Yahya Ayashi, Mosaed Bsheer Alrowili, Jamela Ali Mohammed Bahkli, Abdulaziz Abdulrhman Saud Alkhthlan, Faisal Khalid A Zakri

This work is licensed under a Creative Commons Attribution 4.0 International License.
Multidisciplinary Management of Diabetic Ketoacidosis as an Emergent Complication of Diabetes: Integrating Epidemiology, Primary Care, Radiology, Pharmacy, Nursing, Dental Hygiene, and Family Medicine in a Community Health Framework
Corresponding Author(s) : Musaad Ibrahim Saleh Altuwayjiri
Saudi Journal of Medicine and Public Health,
Vol. 2 No. 2 (2025)
Abstract
Background: Diabetic ketoacidosis (DKA) is a life threatening metabolic emergency characterized by hyperglycemia, ketonemia, and metabolic acidosis. It affects individuals with both type 1 and type 2 diabetes and is precipitated by infection, nonadherence to therapy, acute illness, and medication related metabolic disturbances. Emerging triggers include SGLT2 inhibitors, GLP 1 receptor agonists, immune checkpoint inhibitors, and substance use.
Aim: To provide an integrated multidisciplinary overview of DKA, encompassing epidemiology, clinical presentation, evaluation, management, and healthcare team collaboration in improving outcomes.
Methods: This article synthesizes evidence from epidemiologic studies, clinical guidelines, and multidisciplinary practice recommendations. It reviews DKA etiology, population level trends, diagnostic standards, biochemical evaluation, and current therapeutic strategies, including fluid resuscitation, insulin protocols, and electrolyte correction. It further analyzes the roles of nursing, pharmacy, radiology, dentistry, epidemiology, and family medicine in optimizing care delivery.
Results: DKA incidence varies significantly across populations, with higher rates in women, minority groups, the elderly, and patients with insulin delivery challenges. Early recognition supported by laboratory criteria—elevated glucose, low pH, low bicarbonate, and high anion gap—remains essential for timely intervention. Standardized treatment involving fluid resuscitation, continuous insulin therapy, and careful electrolyte replacement has significantly reduced mortality. Multidisciplinary collaboration enhances diagnostic accuracy, reduces complications, prevents recurrence, and supports long term glycemic control.
Conclusion: Given its multifactorial triggers and potentially fatal complications, DKA requires coordinated, evidence based, multidisciplinary management. Comprehensive evaluation, guideline driven treatment, and interprofessional collaboration are critical to reducing morbidity, preventing recurrence, and improving patient outcomes.
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- Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114.
- Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009 Jul;32(7):1335-43.
- Chow E, Clement S, Garg R. Euglycemic diabetic ketoacidosis in the era of SGLT-2 inhibitors. BMJ Open Diabetes Res Care. 2023 Oct;11(5)
- Rawla P, Vellipuram AR, Bandaru SS, Pradeep Raj J. Euglycemic diabetic ketoacidosis: a diagnostic and therapeutic dilemma. Endocrinol Diabetes Metab Case Rep. 2017;2017
- Taylor SI, Blau JE, Rother KI. SGLT2 Inhibitors May Predispose to Ketoacidosis. J Clin Endocrinol Metab. 2015 Aug;100(8):2849-52.
- Thaibah HA, Banji OJF, Banji D, Alshammari TM. Diabetic Ketoacidosis and the Use of New Hypoglycemic Groups: Real-World Evidence Utilizing the Food and Drug Administration Adverse Event Reporting System. Pharmaceuticals (Basel). 2025 Feb 05;18(2)
- Patel N, Reddy A, Romero KN, Reddy P. Euglycemic Diabetic Ketoacidosis in the Setting of Dulaglutide Use. Cureus. 2025 Apr;17(4):e82143.
- Dhanasekaran M, Mohan S, Erickson D, Shah P, Szymanski L, Adrian V, Egan AM. Diabetic Ketoacidosis in Pregnancy: Clinical Risk Factors, Presentation, and Outcomes. J Clin Endocrinol Metab. 2022 Nov 23;107(11):3137-3143.
- Gosmanov AR, Kitabchi AE. Diabetic Ketoacidosis. In: Feingold KR, Ahmed SF, Anawalt B, Blackman MR, Boyce A, Chrousos G, Corpas E, de Herder WW, Dhatariya K, Dungan K, Hofland J, Kalra S, Kaltsas G, Kapoor N, Koch C, Kopp P, Korbonits M, Kovacs CS, Kuohung W, Laferrère B, Levy M, McGee EA, McLachlan R, Muzumdar R, Purnell J, Rey R, Sahay R, Shah AS, Singer F, Sperling MA, Stratakis CA, Trence DL, Wilson DP, editors. Endotext [Internet]. MDText.com, Inc.; South Dartmouth (MA): Apr 28, 2018.
- Alduraibi RK, Altowayan YF, AlMharwal BT. Unexpected cause of recurrent diabetic ketoacidosis in type 1 diabetes: a case report. BMC Endocr Disord. 2023 Jul 03;23(1):137.
- Fazeli Farsani S, Brodovicz K, Soleymanlou N, Marquard J, Wissinger E, Maiese BA. Incidence and prevalence of diabetic ketoacidosis (DKA) among adults with type 1 diabetes mellitus (T1D): a systematic literature review. BMJ Open. 2017 Aug 01;7(7):e016587.
- Große J, Hornstein H, Manuwald U, Kugler J, Glauche I, Rothe U. Incidence of Diabetic Ketoacidosis of New-Onset Type 1 Diabetes in Children and Adolescents in Different Countries Correlates with Human Development Index (HDI): An Updated Systematic Review, Meta-Analysis, and Meta-Regression. Horm Metab Res. 2018 Mar;50(3):209-222.
- Wachtel TJ, Tetu-Mouradjian LM, Goldman DL, Ellis SE, O'Sullivan PS. Hyperosmolarity and acidosis in diabetes mellitus: a three-year experience in Rhode Island. J Gen Intern Med. 1991 Nov-Dec;6(6):495-502.
- Umpierrez GE, Kelly JP, Navarrete JE, Casals MM, Kitabchi AE. Hyperglycemic crises in urban blacks. Arch Intern Med. 1997 Mar 24;157(6):669-75.
- Benoit SR, Zhang Y, Geiss LS, Gregg EW, Albright A. Trends in Diabetic Ketoacidosis Hospitalizations and In-Hospital Mortality - United States, 2000-2014. MMWR Morb Mortal Wkly Rep. 2018 Mar 30;67(12):362-365.
- Wang J, Williams DE, Narayan KM, Geiss LS. Declining death rates from hyperglycemic crisis among adults with diabetes, U.S., 1985-2002. Diabetes Care. 2006 Sep;29(9):2018-22.
- Gaglia JL, Wyckoff J, Abrahamson MJ. Acute hyperglycemic crisis in the elderly. Med Clin North Am. 2004 Jul;88(4):1063-84, xii.
- Philippe J. Insulin regulation of the glucagon gene is mediated by an insulin-responsive DNA element. Proc Natl Acad Sci U S A. 1991 Aug 15;88(16):7224-7.
- Kaur J, Seaquist ER. Translational aspects of glucagon: current use and future prospects. J Endocrinol. 2023 Apr 01;257(1)
- Umpierrez GE, Davis GM, ElSayed NA, Fadini GP, Galindo RJ, Hirsch IB, Klonoff DC, McCoy RG, Misra S, Gabbay RA, Bannuru RR, Dhatariya KK. Hyperglycemic Crises in Adults With Diabetes: A Consensus Report. Diabetes Care. 2024 Aug 01;47(8):1257-1275.
- Barnes AJ, Bloom SR, Goerge K, Alberti GM, Smythe P, Alford FP, Chisholm DJ. Ketoacidosis in pancreatectomized man. N Engl J Med. 1977 Jun 02;296(22):1250-3.
- Fulop M, Tannenbaum H, Dreyer N. Ketotic hyperosmolar coma. Lancet. 1973 Sep 22;2(7830):635-9.
- Umpierrez G, Freire AX. Abdominal pain in patients with hyperglycemic crises. J Crit Care. 2002 Mar;17(1):63-7.
- Lorber D. Nonketotic hypertonicity in diabetes mellitus. Med Clin North Am. 1995 Jan;79(1):39-52.
- Umpierrez GE, Khajavi M, Kitabchi AE. Review: diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic syndrome. Am J Med Sci. 1996 May;311(5):225-33.
- Paulson WD, Gadallah MF. Diagnosis of mixed acid-base disorders in diabetic ketoacidosis. Am J Med Sci. 1993 Nov;306(5):295-300.
- Dhatariya KK, Glaser NS, Codner E, Umpierrez GE. Diabetic ketoacidosis. Nat Rev Dis Primers. 2020 May 14;6(1):40.
- Kitabchi AE, Umpierrez GE, Murphy MB, Barrett EJ, Kreisberg RA, Malone JI, Wall BM. Management of hyperglycemic crises in patients with diabetes. Diabetes Care. 2001 Jan;24(1):131-53.
- Molitch ME, Rodman E, Hirsch CA, Dubinsky E. Spurious serum creatinine elevations in ketoacidosis. Ann Intern Med. 1980 Aug;93(2):280-1.
- Warshaw AL, Feller ER, Lee KH. On the cause of raised serum-amylase in diabetic ketoacidosis. Lancet. 1977 Apr 30;1(8018):929-31.
- Vantyghem MC, Haye S, Balduyck M, Hober C, Degand PM, Lefebvre J. Changes in serum amylase, lipase and leukocyte elastase during diabetic ketoacidosis and poorly controlled diabetes. Acta Diabetol. 1999 Jun;36(1-2):39-44.
- Weidman SW, Ragland JB, Fisher JN, Kitabchi AE, Sabesin SM. Effects of insulin on plasma lipoproteins in diabetic ketoacidosis: evidence for a change in high density lipoprotein composition during treatment. J Lipid Res. 1982 Jan;23(1):171-82.
- Elendu C, David JA, Udoyen AO, Egbunu EO, Ogbuiyi-Chima IC, Unakalamba LO, Temitope AI, Ibhiedu JO, Ibhiedu AO, Nwosu PU, Koroyin MO, Eze C, Boluwatife AI, Alabi O, Okabekwa OS, Fatoye JO, Ramon-Yusuf HI. Comprehensive review of diabetic ketoacidosis: an update. Ann Med Surg (Lond). 2023 Jun;85(6):2802-2807.
- Perel P, Roberts I, Ker K. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2013 Feb 28;(2):CD000567.
- Mahler SA, Conrad SA, Wang H, Arnold TC. Resuscitation with balanced electrolyte solution prevents hyperchloremic metabolic acidosis in patients with diabetic ketoacidosis. Am J Emerg Med. 2011 Jul;29(6):670-4.
- Chua HR, Venkatesh B, Stachowski E, Schneider AG, Perkins K, Ladanyi S, Kruger P, Bellomo R. Plasma-Lyte 148 vs 0.9% saline for fluid resuscitation in diabetic ketoacidosis. J Crit Care. 2012 Apr;27(2):138-45.
- Van Zyl DG, Rheeder P, Delport E. Fluid management in diabetic-acidosis--Ringer's lactate versus normal saline: a randomized controlled trial. QJM. 2012 Apr;105(4):337-43.
- Adrogué HJ, Barrero J, Eknoyan G. Salutary effects of modest fluid replacement in the treatment of adults with diabetic ketoacidosis. Use in patients without extreme volume deficit. JAMA. 1989 Oct 20;262(15):2108-13.
- Edge JA, Jakes RW, Roy Y, Hawkins M, Winter D, Ford-Adams ME, Murphy NP, Bergomi A, Widmer B, Dunger DB. The UK case-control study of cerebral oedema complicating diabetic ketoacidosis in children. Diabetologia. 2006 Sep;49(9):2002-9.
- Dhatariya K, Mustafa O, Stathi D. Hyperglycemic Crises. In: Feingold KR, Ahmed SF, Anawalt B, Blackman MR, Boyce A, Chrousos G, Corpas E, de Herder WW, Dhatariya K, Dungan K, Hofland J, Kalra S, Kaltsas G, Kapoor N, Koch C, Kopp P, Korbonits M, Kovacs CS, Kuohung W, Laferrère B, Levy M, McGee EA, McLachlan R, Muzumdar R, Purnell J, Rey R, Sahay R, Shah AS, Singer F, Sperling MA, Stratakis CA, Trence DL, Wilson DP, editors. Endotext [Internet]. MDText.com, Inc.; South Dartmouth (MA): Jun 10, 2025.
- Kitabchi AE, Murphy MB, Spencer J, Matteri R, Karas J. Is a priming dose of insulin necessary in a low-dose insulin protocol for the treatment of diabetic ketoacidosis? Diabetes Care. 2008 Nov;31(11):2081-5.
- Umpierrez GE, Latif K, Stoever J, Cuervo R, Park L, Freire AX, E Kitabchi A. Efficacy of subcutaneous insulin lispro versus continuous intravenous regular insulin for the treatment of patients with diabetic ketoacidosis. Am J Med. 2004 Sep 01;117(5):291-6.
- Razavi Z, Maher S, Fredmal J. Comparison of subcutaneous insulin aspart and intravenous regular insulin for the treatment of mild and moderate diabetic ketoacidosis in pediatric patients. Endocrine. 2018 Aug;61(2):267-274.
- Nyenwe EA, Kitabchi AE. The evolution of diabetic ketoacidosis: An update of its etiology, pathogenesis and management. Metabolism. 2016 Apr;65(4):507-21.
- Pasquel FJ, Umpierrez GE. Hyperosmolar hyperglycemic state: a historic review of the clinical presentation, diagnosis, and treatment. Diabetes Care. 2014 Nov;37(11):3124-31.
- Herpes virus fingerprinting. Lancet. 1979 Feb 03;1(8110):251-2.
- Fayfman M, Pasquel FJ, Umpierrez GE. Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. Med Clin North Am. 2017 May;101(3):587-606.
- Duhon B, Attridge RL, Franco-Martinez AC, Maxwell PR, Hughes DW. Intravenous sodium bicarbonate therapy in severely acidotic diabetic ketoacidosis. Ann Pharmacother. 2013 Jul-Aug;47(7-8):970-5.
- Glaser N, Barnett P, McCaslin I, Nelson D, Trainor J, Louie J, Kaufman F, Quayle K, Roback M, Malley R, Kuppermann N., Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. Risk factors for cerebral edema in children with diabetic ketoacidosis. The Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. N Engl J Med. 2001 Jan 25;344(4):264-9.
- Osuka A, Matsuoka T, Idoguchi K. Is this the worst outcome of metabolic syndrome? Hypophosphatemia and resulting cardiac arrest during the treatment of diabetic ketoacidosis with hypertriglyceridemia. Intern Med. 2009;48(16):1391-5.
- Kaur J, Castro D. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Feb 12, 2024. Hypophosphatemia.
- Regmi A, Konstantinov NK, Agaba EI, Rohrscheib M, Dorin RI, Tzamaloukas AH. Respiratory Failure in the Course of Treatment of Diabetic Ketoacidosis. Clin Diabetes. 2014 Jan;32(1):28-31.
- Choudhury A, Ravikant, Bairwa M, Jithesh G, Kumar S, Kumar N. Efficacy of Intravenous 20% Mannitol vs 3% Hypertonic Saline in Reducing Intracranial Pressure in Nontraumatic Brain Injury: A Systematic Review and Meta-analysis. Indian J Crit Care Med. 2024 Jul;28(7):686-695.
References
Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114.
Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009 Jul;32(7):1335-43.
Chow E, Clement S, Garg R. Euglycemic diabetic ketoacidosis in the era of SGLT-2 inhibitors. BMJ Open Diabetes Res Care. 2023 Oct;11(5)
Rawla P, Vellipuram AR, Bandaru SS, Pradeep Raj J. Euglycemic diabetic ketoacidosis: a diagnostic and therapeutic dilemma. Endocrinol Diabetes Metab Case Rep. 2017;2017
Taylor SI, Blau JE, Rother KI. SGLT2 Inhibitors May Predispose to Ketoacidosis. J Clin Endocrinol Metab. 2015 Aug;100(8):2849-52.
Thaibah HA, Banji OJF, Banji D, Alshammari TM. Diabetic Ketoacidosis and the Use of New Hypoglycemic Groups: Real-World Evidence Utilizing the Food and Drug Administration Adverse Event Reporting System. Pharmaceuticals (Basel). 2025 Feb 05;18(2)
Patel N, Reddy A, Romero KN, Reddy P. Euglycemic Diabetic Ketoacidosis in the Setting of Dulaglutide Use. Cureus. 2025 Apr;17(4):e82143.
Dhanasekaran M, Mohan S, Erickson D, Shah P, Szymanski L, Adrian V, Egan AM. Diabetic Ketoacidosis in Pregnancy: Clinical Risk Factors, Presentation, and Outcomes. J Clin Endocrinol Metab. 2022 Nov 23;107(11):3137-3143.
Gosmanov AR, Kitabchi AE. Diabetic Ketoacidosis. In: Feingold KR, Ahmed SF, Anawalt B, Blackman MR, Boyce A, Chrousos G, Corpas E, de Herder WW, Dhatariya K, Dungan K, Hofland J, Kalra S, Kaltsas G, Kapoor N, Koch C, Kopp P, Korbonits M, Kovacs CS, Kuohung W, Laferrère B, Levy M, McGee EA, McLachlan R, Muzumdar R, Purnell J, Rey R, Sahay R, Shah AS, Singer F, Sperling MA, Stratakis CA, Trence DL, Wilson DP, editors. Endotext [Internet]. MDText.com, Inc.; South Dartmouth (MA): Apr 28, 2018.
Alduraibi RK, Altowayan YF, AlMharwal BT. Unexpected cause of recurrent diabetic ketoacidosis in type 1 diabetes: a case report. BMC Endocr Disord. 2023 Jul 03;23(1):137.
Fazeli Farsani S, Brodovicz K, Soleymanlou N, Marquard J, Wissinger E, Maiese BA. Incidence and prevalence of diabetic ketoacidosis (DKA) among adults with type 1 diabetes mellitus (T1D): a systematic literature review. BMJ Open. 2017 Aug 01;7(7):e016587.
Große J, Hornstein H, Manuwald U, Kugler J, Glauche I, Rothe U. Incidence of Diabetic Ketoacidosis of New-Onset Type 1 Diabetes in Children and Adolescents in Different Countries Correlates with Human Development Index (HDI): An Updated Systematic Review, Meta-Analysis, and Meta-Regression. Horm Metab Res. 2018 Mar;50(3):209-222.
Wachtel TJ, Tetu-Mouradjian LM, Goldman DL, Ellis SE, O'Sullivan PS. Hyperosmolarity and acidosis in diabetes mellitus: a three-year experience in Rhode Island. J Gen Intern Med. 1991 Nov-Dec;6(6):495-502.
Umpierrez GE, Kelly JP, Navarrete JE, Casals MM, Kitabchi AE. Hyperglycemic crises in urban blacks. Arch Intern Med. 1997 Mar 24;157(6):669-75.
Benoit SR, Zhang Y, Geiss LS, Gregg EW, Albright A. Trends in Diabetic Ketoacidosis Hospitalizations and In-Hospital Mortality - United States, 2000-2014. MMWR Morb Mortal Wkly Rep. 2018 Mar 30;67(12):362-365.
Wang J, Williams DE, Narayan KM, Geiss LS. Declining death rates from hyperglycemic crisis among adults with diabetes, U.S., 1985-2002. Diabetes Care. 2006 Sep;29(9):2018-22.
Gaglia JL, Wyckoff J, Abrahamson MJ. Acute hyperglycemic crisis in the elderly. Med Clin North Am. 2004 Jul;88(4):1063-84, xii.
Philippe J. Insulin regulation of the glucagon gene is mediated by an insulin-responsive DNA element. Proc Natl Acad Sci U S A. 1991 Aug 15;88(16):7224-7.
Kaur J, Seaquist ER. Translational aspects of glucagon: current use and future prospects. J Endocrinol. 2023 Apr 01;257(1)
Umpierrez GE, Davis GM, ElSayed NA, Fadini GP, Galindo RJ, Hirsch IB, Klonoff DC, McCoy RG, Misra S, Gabbay RA, Bannuru RR, Dhatariya KK. Hyperglycemic Crises in Adults With Diabetes: A Consensus Report. Diabetes Care. 2024 Aug 01;47(8):1257-1275.
Barnes AJ, Bloom SR, Goerge K, Alberti GM, Smythe P, Alford FP, Chisholm DJ. Ketoacidosis in pancreatectomized man. N Engl J Med. 1977 Jun 02;296(22):1250-3.
Fulop M, Tannenbaum H, Dreyer N. Ketotic hyperosmolar coma. Lancet. 1973 Sep 22;2(7830):635-9.
Umpierrez G, Freire AX. Abdominal pain in patients with hyperglycemic crises. J Crit Care. 2002 Mar;17(1):63-7.
Lorber D. Nonketotic hypertonicity in diabetes mellitus. Med Clin North Am. 1995 Jan;79(1):39-52.
Umpierrez GE, Khajavi M, Kitabchi AE. Review: diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic syndrome. Am J Med Sci. 1996 May;311(5):225-33.
Paulson WD, Gadallah MF. Diagnosis of mixed acid-base disorders in diabetic ketoacidosis. Am J Med Sci. 1993 Nov;306(5):295-300.
Dhatariya KK, Glaser NS, Codner E, Umpierrez GE. Diabetic ketoacidosis. Nat Rev Dis Primers. 2020 May 14;6(1):40.
Kitabchi AE, Umpierrez GE, Murphy MB, Barrett EJ, Kreisberg RA, Malone JI, Wall BM. Management of hyperglycemic crises in patients with diabetes. Diabetes Care. 2001 Jan;24(1):131-53.
Molitch ME, Rodman E, Hirsch CA, Dubinsky E. Spurious serum creatinine elevations in ketoacidosis. Ann Intern Med. 1980 Aug;93(2):280-1.
Warshaw AL, Feller ER, Lee KH. On the cause of raised serum-amylase in diabetic ketoacidosis. Lancet. 1977 Apr 30;1(8018):929-31.
Vantyghem MC, Haye S, Balduyck M, Hober C, Degand PM, Lefebvre J. Changes in serum amylase, lipase and leukocyte elastase during diabetic ketoacidosis and poorly controlled diabetes. Acta Diabetol. 1999 Jun;36(1-2):39-44.
Weidman SW, Ragland JB, Fisher JN, Kitabchi AE, Sabesin SM. Effects of insulin on plasma lipoproteins in diabetic ketoacidosis: evidence for a change in high density lipoprotein composition during treatment. J Lipid Res. 1982 Jan;23(1):171-82.
Elendu C, David JA, Udoyen AO, Egbunu EO, Ogbuiyi-Chima IC, Unakalamba LO, Temitope AI, Ibhiedu JO, Ibhiedu AO, Nwosu PU, Koroyin MO, Eze C, Boluwatife AI, Alabi O, Okabekwa OS, Fatoye JO, Ramon-Yusuf HI. Comprehensive review of diabetic ketoacidosis: an update. Ann Med Surg (Lond). 2023 Jun;85(6):2802-2807.
Perel P, Roberts I, Ker K. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2013 Feb 28;(2):CD000567.
Mahler SA, Conrad SA, Wang H, Arnold TC. Resuscitation with balanced electrolyte solution prevents hyperchloremic metabolic acidosis in patients with diabetic ketoacidosis. Am J Emerg Med. 2011 Jul;29(6):670-4.
Chua HR, Venkatesh B, Stachowski E, Schneider AG, Perkins K, Ladanyi S, Kruger P, Bellomo R. Plasma-Lyte 148 vs 0.9% saline for fluid resuscitation in diabetic ketoacidosis. J Crit Care. 2012 Apr;27(2):138-45.
Van Zyl DG, Rheeder P, Delport E. Fluid management in diabetic-acidosis--Ringer's lactate versus normal saline: a randomized controlled trial. QJM. 2012 Apr;105(4):337-43.
Adrogué HJ, Barrero J, Eknoyan G. Salutary effects of modest fluid replacement in the treatment of adults with diabetic ketoacidosis. Use in patients without extreme volume deficit. JAMA. 1989 Oct 20;262(15):2108-13.
Edge JA, Jakes RW, Roy Y, Hawkins M, Winter D, Ford-Adams ME, Murphy NP, Bergomi A, Widmer B, Dunger DB. The UK case-control study of cerebral oedema complicating diabetic ketoacidosis in children. Diabetologia. 2006 Sep;49(9):2002-9.
Dhatariya K, Mustafa O, Stathi D. Hyperglycemic Crises. In: Feingold KR, Ahmed SF, Anawalt B, Blackman MR, Boyce A, Chrousos G, Corpas E, de Herder WW, Dhatariya K, Dungan K, Hofland J, Kalra S, Kaltsas G, Kapoor N, Koch C, Kopp P, Korbonits M, Kovacs CS, Kuohung W, Laferrère B, Levy M, McGee EA, McLachlan R, Muzumdar R, Purnell J, Rey R, Sahay R, Shah AS, Singer F, Sperling MA, Stratakis CA, Trence DL, Wilson DP, editors. Endotext [Internet]. MDText.com, Inc.; South Dartmouth (MA): Jun 10, 2025.
Kitabchi AE, Murphy MB, Spencer J, Matteri R, Karas J. Is a priming dose of insulin necessary in a low-dose insulin protocol for the treatment of diabetic ketoacidosis? Diabetes Care. 2008 Nov;31(11):2081-5.
Umpierrez GE, Latif K, Stoever J, Cuervo R, Park L, Freire AX, E Kitabchi A. Efficacy of subcutaneous insulin lispro versus continuous intravenous regular insulin for the treatment of patients with diabetic ketoacidosis. Am J Med. 2004 Sep 01;117(5):291-6.
Razavi Z, Maher S, Fredmal J. Comparison of subcutaneous insulin aspart and intravenous regular insulin for the treatment of mild and moderate diabetic ketoacidosis in pediatric patients. Endocrine. 2018 Aug;61(2):267-274.
Nyenwe EA, Kitabchi AE. The evolution of diabetic ketoacidosis: An update of its etiology, pathogenesis and management. Metabolism. 2016 Apr;65(4):507-21.
Pasquel FJ, Umpierrez GE. Hyperosmolar hyperglycemic state: a historic review of the clinical presentation, diagnosis, and treatment. Diabetes Care. 2014 Nov;37(11):3124-31.
Herpes virus fingerprinting. Lancet. 1979 Feb 03;1(8110):251-2.
Fayfman M, Pasquel FJ, Umpierrez GE. Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. Med Clin North Am. 2017 May;101(3):587-606.
Duhon B, Attridge RL, Franco-Martinez AC, Maxwell PR, Hughes DW. Intravenous sodium bicarbonate therapy in severely acidotic diabetic ketoacidosis. Ann Pharmacother. 2013 Jul-Aug;47(7-8):970-5.
Glaser N, Barnett P, McCaslin I, Nelson D, Trainor J, Louie J, Kaufman F, Quayle K, Roback M, Malley R, Kuppermann N., Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. Risk factors for cerebral edema in children with diabetic ketoacidosis. The Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. N Engl J Med. 2001 Jan 25;344(4):264-9.
Osuka A, Matsuoka T, Idoguchi K. Is this the worst outcome of metabolic syndrome? Hypophosphatemia and resulting cardiac arrest during the treatment of diabetic ketoacidosis with hypertriglyceridemia. Intern Med. 2009;48(16):1391-5.
Kaur J, Castro D. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Feb 12, 2024. Hypophosphatemia.
Regmi A, Konstantinov NK, Agaba EI, Rohrscheib M, Dorin RI, Tzamaloukas AH. Respiratory Failure in the Course of Treatment of Diabetic Ketoacidosis. Clin Diabetes. 2014 Jan;32(1):28-31.
Choudhury A, Ravikant, Bairwa M, Jithesh G, Kumar S, Kumar N. Efficacy of Intravenous 20% Mannitol vs 3% Hypertonic Saline in Reducing Intracranial Pressure in Nontraumatic Brain Injury: A Systematic Review and Meta-analysis. Indian J Crit Care Med. 2024 Jul;28(7):686-695.