is an acute, potentially life-threatening complication of diabetes mellitus. For the most part, DKA occurs in people with
type 1 diabetes,
it can happen in folks
type 2 diabetes
almost as often.
DKA is the result of an inadequate amount of insulin. Insulin allows the body to use its major fuel source (glucose) for energy. Since glucose can no longer be burned,
it reaches high levels in the bloodstream. This causes increased urine production and dehydration.
About 10% of total body fluids are lost as the patient slips into diabetic ketoacidosis.
When there is not enough insulin, the body burns fat instead. Fat breaks down into acids which in turn produce toxic acidic substances known as
These build in the bloodstream causing a dangerous situation.
Loss of potassium and other salts which the body needs in the excessive urination is also common.
DKA is therefore a medical emergency which if untreated can result in coma and possibly death. In the early stages, it may be possible
to treat DKA at home, but if it is more advanced, management should take place in a properly equipped setting such as a
hospital. The keys to prevention of DKA include awareness of its warning signs along with frequent blood glucose monitoring and checking
urine or blood ketone levels as needed.
The most common events that cause a person with diabetes to develop diabetic ketoacidosis are:
Infection such as diarrhea, vomiting, and/or high fever (40%),
- Missed, inadequate, or “bad” insulin (25%),
- New diagnosis or previously unknown diabetes (15%).
- Various other causes: pregnancy, heart attack, stroke, trauma,
drug abuse, and surgery.
- Approximately 5% to 10% of cases have
no identifiable cause.
Signs and Symptoms
symptoms of diabetic ketoacidosis evolve over a 24-hour period. The most common symptoms include:
- Polydisia (excessive thirst)
- Polyuria (marked increase in urination)
- Fruity odor to the breath
Abdominal pain (which may be mistaken for conditions like pancreatitis, appendicitis, or gastrointestinal perforation)
- Increase in blood glucose levels which persists over time
As DKA progresses into its more severe forms, you may also see:
- Signs of dehydraton (dry mouth, increased heart rate, low blood pressure)
- Rapid deep labored breathing
- Coffeeground vomiting
- Changes in consciousness and/or behavior
Diagnosing DKA is relatively straightforward. Venous blood and a urine samples are analyzed for gluose and ketones. A high blood glucose level along with the
presence of ketone bodies in either the blood or urine are diagnostic of DKA.
An arterial specimen for the measurement of blood gases is also taken to confirm acidosis.
Additional blood samples are usually taken to assess electrolytes (sodium, potassium, chloride and bicarbonate) and kidney function (urea
creatinine) which can become compromised because of severe dehydration. Other testing may be done for signs of infection and conditions
such as pancreatitis.
A CAT scan may also be performed if cerebral edema or stroke is suspected as may be manifested by lethargy, confusion, muscle weakness, recurrent vomiting, etc.
Classification of Severity
In a position statement,
classifies diabetic ketoacidosis as mild moderate or severe according to laboratory values and symptomatology
Diagnostic criteria and typical total body deficits of water and electrolytes
in DKA and HHS).
European Society for Paediatric Endocrinology/Lawson Wilkins Pediatric Endocrine Society Consensus Statement on Diabetic Ketoacidosis in Children and Adolescents2 states
"DKA is generally categorized by the severity of the acidosis, varying from mild (venous pH: <7.30; bicarbonate concentration: <15 mmol/L) to moderate
(pH: <7.2; bicarbonate: <10) to severe (pH: <7.1; bicarbonate: <5)."
The overall aims of treatment are to restore the body’s metabolic balance, replenish lost fluid and
electrolytes, correct the hyperglycemia, and stop ketone production. Depending on the severity of the DKA and the need for close observation, admission to
an intensive care unit or similarly equipped facility may be warranted. Primary components
of therapy are: fluid, insulin, and potassium replacement along with identification and management of precipitating factors.
The American Diabetes position statement contains very clear protocols for the management of both adults (Management of Adult Patients with DKA)
(Management of Pediatric (<20 years) Patients with DKA).
Data are clear that many cases of DKA are preventable. Since the overall costs of this disorder in terms of morbidity/mortality and the economic strain it places on
the health care system (approximately one out of every two healthcare dollars allocated for diabetes are spent)
are great, careful emphasis and attention needs to be focused on prevention
of DKA. Mechanisms which help include:
- Better access to quality diabetes care and education
- Provision of needed management tools such as monitoring equipment, insulin, and syringes.
- Better education of primary care providers.
- Improved communications with health care providers during episodes of acute illness.
- Provision of guidelines as to when to call for help and sick day management.
The Bottom Line
Diabetic ketoacidosis is a serious and potentially lethal complication of diabetes. With the support of your healthcare team, you should be able to detect early warning
signs and avoid progression of this devastating diabetes complication. A few guidelines to help:
- Monitor blood glucose levels frequently. If levels are greater than 240 mg//dl, check urine or blood ketone levels.
- Never discontinue insulin.
- Ask your healthcare team for guidelines to assist you in managing sick days and episodes of hyperglycemia.
- Learn the
signs and symptoms of DKA
- If you are sick, call your doctor if your illness increases blood glucose levels and causes urine ketones.
See your doctor or go to an emergency room without delay if there is no improvement in 6–8 hours or you have signs of DKA.
- When consulting your healthcare team, have your monitoring results available.
Hyperglycemic Crises in Adult Patients With Diabetes.
A consensus statement from the American Diabetes Association.
European Society for Paediatric Endocrinology/Lawson Wilkins Pediatric Endocrine
Society Consensus Statement on Diabetic Ketoacidosis in Children and Adolescents
For more information
Diabetic Ketoacidosis From eMedicineHealth.
Diabetic Ketoacidosis at Wikipedia.
From the ADA.