Study Finds One-Third of ED Patients Diagnosed With DKA Despite Not Meeting Laboratory Criteria
USA: A new study published in Academic Emergency Medicine suggests that emergency physicians frequently diagnose diabetic ketoacidosis (DKA) based on the overall clinical picture rather than laboratory findings alone. Researchers found that nearly one-third of patients whose initial laboratory results did not meet standard DKA criteria were still diagnosed with the condition, highlighting the importance of clinical judgment in emergency care.
DKA is a serious, potentially life-threatening complication of diabetes characterized by hyperglycemia, ketosis, and metabolic acidosis. Although established laboratory criteria are commonly used to confirm the diagnosis, patients often present with overlapping clinical features that may not fully satisfy these laboratory thresholds. To better understand how DKA is diagnosed in routine emergency practice, the investigators examined the relationship between laboratory findings and physicians' clinical diagnoses.
For this purpose, Richard T. Griffey from Washington University School of Medicine in St. Louis and colleagues conducted a retrospective observational study at a large urban academic emergency department between January 2019 and February 2023. The analysis included 1,676 adults with point-of-care glucose levels above 300 mg/dL and elevated ketone levels or an emergency department diagnosis of DKA. DKA was defined using standard laboratory criteria based on blood pH, bicarbonate concentration, or, when blood gas measurements were unavailable, anion gap and carbon dioxide levels.
The study led to the following findings:
- Overall, 53% of patients met at least one laboratory criterion for diabetic ketoacidosis (DKA).
- Among patients meeting laboratory criteria, 88% qualified based on abnormal pH and bicarbonate levels, while 12% met criteria based on anion gap and carbon dioxide levels.
- Overall, 87.3% of patients received an emergency department diagnosis of DKA.
- Among 740 patients with positive point-of-care screening but no initial laboratory evidence of DKA, 31% were still diagnosed with DKA.
- Only 7.4% of patients diagnosed with DKA despite not meeting initial laboratory criteria later developed laboratory findings consistent with DKA.
- Among patients who neither met laboratory criteria nor received a DKA diagnosis, the most common alternative diagnoses were hyperglycemia, infection, starvation ketosis, and hyperosmolar hyperglycemic state (HHS).
- One-third of patients without a DKA diagnosis received unrelated primary diagnoses, highlighting the diverse causes of hyperglycemia, ketosis, and metabolic abnormalities.
The researchers acknowledged several limitations, including the retrospective design, reliance on electronic medical records and coded diagnoses, limited insight into clinical decision-making, inconsistent documentation of diabetes type, and the exclusion of patients with euglycemic DKA associated with SGLT2 inhibitors or GLP-1 receptor agonists.
The researchers concluded that emergency physicians often diagnose DKA despite the absence of initial laboratory criteria, underscoring the importance of clinical assessment. They suggested that DKA should be viewed as a clinical syndrome rather than a diagnosis based solely on laboratory findings.
Reference:
Griffey, R. T., Haas, N., Schneider, R. M., Suarez, D., Kline, J. A., Ancona, R., & Cruz-Bravo, P. (2026). How Often Are Emergency Patients Diagnosed With Diabetic Ketoacidosis Despite Not Meeting Laboratory Criteria? Academic Emergency Medicine, 33(5), e70315. https://doi.org/10.1111/acem.70315
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