# Situation: A 22-year-old woman with type 1 diabetes mellitus is brought to the emergency department after two days of vomiting, during which she stopped taking her insulin. She weighs 58 kg. Diabetic ketoacidosis (DKA) is diagnosed, and she is admitted to the intensive care unit. The team will begin the change to subcutaneous insulin only when DKA has resolved according to the 2024 consensus. Blood ketones are measured as beta-hydroxybutyrate, and pH is measured on a venous sample. Which set of results shows that DKA has resolved?

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## 문제

Situation: A 22-year-old woman with type 1 diabetes mellitus is brought to the emergency department after two days of vomiting, during which she stopped taking her insulin. She weighs 58 kg. Diabetic ketoacidosis (DKA) is diagnosed, and she is admitted to the intensive care unit.

The team will begin the change to subcutaneous insulin only when DKA has resolved according to the 2024 consensus. Blood ketones are measured as beta-hydroxybutyrate, and pH is measured on a venous sample. Which set of results shows that DKA has resolved?

## 보기

1. Glucose 196 mg/dL (10.9 mmol/L), ketones 0.5 mmol/L, pH 7.27, bicarbonate 16 mEq/L
2. Glucose 214 mg/dL (11.9 mmol/L), ketones 0.4 mmol/L, pH 7.31, bicarbonate 17 mEq/L **✔ 정답**
3. Glucose 162 mg/dL (9.0 mmol/L), ketones 1.4 mmol/L, pH 7.33, bicarbonate 19 mEq/L
4. Glucose 138 mg/dL (7.7 mmol/L), ketones 0.8 mmol/L, pH 7.36, bicarbonate 21 mEq/L

**정답: 2**

## 해설

DKA has resolved when blood ketones are below 0.6 mmol/L AND either venous pH is 7.3 or higher OR bicarbonate is 18 mEq/L or higher. Glucose is not a resolution criterion. Only the set with ketones 0.4 mmol/L and venous pH 7.31 meets the ketone rule and one of the two acid–base rules, even though its glucose is the highest and its bicarbonate is still below 18.

## 심화 해설

DKA Resolution Criteria — 2024 Consensus

The transition from intravenous to subcutaneous insulin is safe only when the ketoacidotic process has truly reversed. The 2024 consensus defines resolution using two independent domains: ketonemia and acid–base status. Glucose concentration is deliberately excluded because hyperglycemia often lags behind metabolic recovery, and normalizing glucose too early can mask ongoing ketogenesis [2].

DKA is resolved when blood beta-hydroxybutyrate falls below 0.6 mmol/L AND either venous pH is 7.3 or higher OR serum bicarbonate is 18 mEq/L or higher. Both conditions must be met simultaneously; meeting only one is insufficient.

| Option | Ketones (BOHB) | Venous pH | Bicarbonate | Meets ketone rule? | Meets acid–base rule? | DKA resolved? |
| --- | --- | --- | --- | --- | --- | --- |
| 1 | 0.5 mmol/L | 7.27 | 16 mEq/L | Yes | No (pH low, HCO3 low) | No |
| 2 | 0.4 mmol/L | 7.31 | 17 mEq/L | Yes | Yes (pH ≥ 7.3) | Yes |
| 3 | 1.4 mmol/L | 7.33 | 19 mEq/L | No | Yes | No |
| 4 | 0.8 mmol/L | 7.36 | 21 mEq/L | No | Yes | No |

Key point! Option 2 has the highest glucose (214 mg/dL) and a bicarbonate still below 18 mEq/L, yet it is the only set that satisfies both the ketone threshold and at least one acid–base criterion. This illustrates why glucose is not a resolution marker and why the acid–base rule uses an “OR” between pH and bicarbonate.

Why beta-hydroxybutyrate matters

In DKA, insulin deficiency shifts hepatic metabolism toward ketogenesis, producing acetoacetate and beta-hydroxybutyrate (BOHB). BOHB is the predominant ketone body in severe DKA and is the most direct biochemical reflection of ongoing ketone production . Traditional urine ketone testing detects acetoacetate but misses BOHB, which can lead to falsely reassuring results during recovery when BOHB is converted back to acetoacetate. Plasma or capillary BOHB measurement provides a real-time assessment of whether ketogenesis has actually stopped .

The 0.6 mmol/L BOHB cut-point represents the threshold below which clinically significant ketoacidosis is considered reversed. Values above this indicate that insulin deficiency is still driving ketone production, even if the pH has begun to normalize .

Why the acid–base rule uses “pH OR bicarbonate”

Venous pH and serum bicarbonate usually move together, but they can diverge in specific situations. A patient with respiratory compensation (hyperventilation) may have a pH that appears acceptable while bicarbonate remains depleted. Conversely, a patient with mixed acid–base disturbances may have a bicarbonate that looks reasonable while pH is still low. The consensus therefore accepts either parameter as sufficient evidence of acid–base recovery, provided the ketone criterion is also met [2].

Watch out! Do not use glucose normalization as a proxy for DKA resolution. A patient can have near-normal glucose while still producing ketones if insulin delivery is inadequate relative to ongoing stress or infection. Conversely, glucose may remain elevated for hours after ketogenesis has stopped due to counter-regulatory hormone effects and insulin resistance [2].

Clinical application to this patient

This 22-year-old woman stopped her insulin during two days of vomiting, creating an absolute insulin deficit. Her weight of 58 kg is relevant for calculating insulin infusion rates, but not for determining resolution. When her BOHB drops below 0.6 mmol/L and her venous pH reaches 7.3 or her bicarbonate reaches 18 mEq/L, the team can safely transition to subcutaneous insulin. Option 2 meets these criteria: ketones 0.4 mmol/L and venous pH 7.31, with bicarbonate still lagging at 17 mEq/L but not disqualifying because the pH rule is satisfied.References (research sources)

- [2]Hyperglycemic crises in adults: A look at the 2024 consensus report.GuidelineRodriguez Alvarez P, San Martin VT, Morey-Vargas OL (2025) · DOI: 10.3949/ccjm.92a.24089

## 임상 시나리오

DKA Resolution Before Subcutaneous Insulin2024 Consensus Criteria in the ICU
Transition from intravenous to subcutaneous insulin only when beta-hydroxybutyrate is below 0.6 mmol/L AND venous pH is 7.3 or higher OR bicarbonate is 18 mEq/L or higher. Both the ketone rule and at least one acid-base rule must be met simultaneously.

Glucose is not a resolution criterion. Hyperglycemia may persist after ketoacidosis has reversed, and normalizing glucose too early can mask ongoing ketogenesis.

CautionDo not stop the insulin infusion based on glucose alone. A patient with glucose 214 mg/dL but ketones 0.4 mmol/L and pH 7.31 has resolved DKA, while a patient with glucose 138 mg/dL but ketones 0.8 mmol/L has not.

## 핵심 개념

- **DKA resolution criteria** — Blood beta-hydroxybutyrate below 0.6 mmol/L plus venous pH 7.3 or higher or bicarbonate 18 mEq/L or higher
- **Beta-hydroxybutyrate** — Predominant ketone body in DKA; most direct biochemical marker of ketonemia
- **Anion gap** — Calculated as sodium minus chloride plus bicarbonate; reflects unmeasured anions including ketones
- **Insulin transition** — Switch from intravenous to subcutaneous insulin once DKA resolution criteria are met
- **Euglycemic DKA** — DKA with glucose below 200 mg/dL; glucose is not a resolution criterion

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