Diabetic Ketoacidosis

What is diabetic ketoacidosis?

Diabetic ketoacidosis, often shortened to DKA, is a serious and potentially life-threatening complication of diabetes. It develops when the body does not have enough insulin, the hormone that allows sugar (glucose) to move from the blood into the cells for energy. Without enough insulin, the cells cannot use glucose, so the body begins breaking down fat for fuel instead. This process produces acids called ketones. When ketones build up faster than the body can remove them, the blood becomes acidic. That combination of high blood sugar, high ketones and acidic blood is what doctors call diabetic ketoacidosis.

If you are asking "what is diabetic ketoacidosis" because you or a family member has diabetes, the short answer is that it is a medical emergency that requires treatment in a hospital. It is not the same as having a high blood sugar reading on its own. High blood sugar is common in diabetes; DKA is what can happen when high blood sugar is combined with a lack of insulin over hours to days.

DKA most often affects people with type 1 diabetes, a condition in which the body produces little or no insulin. In some people, DKA is actually the first sign that they have type 1 diabetes, before a diagnosis has been made. It can also occur in people with type 2 diabetes, particularly during severe illness, infection or other physical stress, although this is less common. Children, teenagers and adults can all develop DKA. The condition is usually managed by emergency medicine teams together with specialists in endocrinology and metabolism, the branch of medicine that deals with hormones and diabetes.

Diabetic ketoacidosis symptoms

Diabetic ketoacidosis symptoms usually develop over a period of hours to a day or two. In many cases the early signs look like ordinary high blood sugar, which is one reason DKA can be missed at first. As the condition progresses, the symptoms become more severe and more distinctive.

Common symptoms include:

• Excessive thirst and a dry mouth
• Frequent urination, including waking at night to urinate
• Nausea and vomiting
• Abdominal (stomach) pain, which can be severe
• Weakness, tiredness or feeling generally unwell
• Fruity- or sweet-smelling breath, sometimes compared to nail polish remover
• Rapid, deep breathing or shortness of breath
• Confusion, difficulty concentrating or drowsiness
• Flushed, dry skin
• High blood sugar readings on a home meter, often accompanied by ketones in urine or blood tests

Doctors often describe DKA in stages. In the early stage, thirst, frequent urination and tiredness dominate. These happen because high blood sugar pulls water out of the body through the kidneys, leading to dehydration. In the later stage, as acid builds up, nausea, vomiting, stomach pain and rapid breathing appear. The rapid breathing is the body’s attempt to blow off carbon dioxide and reduce the acid in the blood. In severe DKA, a person may become very drowsy or lose consciousness. This is a critical emergency.

Symptoms can differ somewhat between people. In young children, irritability, unusual sleepiness and heavy breathing may be more noticeable than complaints of thirst. In people who have not yet been diagnosed with diabetes, unexplained weight loss over several weeks often comes before the acute symptoms. In people with type 2 diabetes, DKA may develop alongside a severe infection or other illness, so symptoms of that illness, such as fever or cough, may be present as well.

Causes and risk factors

Diabetic ketoacidosis causes all share one feature: the body does not have enough working insulin to meet its needs. This can happen because insulin is missing, because a dose was not taken, or because the body suddenly needs far more insulin than usual due to stress or illness.

Common triggers include:

• Missed or insufficient insulin doses. Skipping injections, running out of insulin, or using insulin that has spoiled from heat or age can all reduce the amount of active insulin in the body.
• Insulin pump problems. A kinked or blocked tube, a dislodged cannula (the small tube under the skin) or a pump failure can interrupt insulin delivery for hours without an obvious warning.
• Infection or acute illness. Infections such as pneumonia, urinary tract infections, flu or gastroenteritis (stomach flu) raise stress hormones, which counteract insulin and increase the need for it.
• Newly developing type 1 diabetes. In people who do not yet know they have diabetes, insulin production falls until DKA develops.
• Other physical stress. Heart attack, stroke, surgery, trauma or pancreatitis (inflammation of the pancreas) can trigger DKA in people with diabetes.
• Certain medications. Some drugs, including corticosteroids and a class of diabetes medicines known as SGLT2 inhibitors, have been associated with an increased risk of ketoacidosis in some people. Your doctor can explain whether this applies to you.
• Alcohol or drug misuse. Heavy drinking or drug use can interfere with eating, insulin dosing and the body’s normal metabolism.

Risk factors that make DKA more likely include having type 1 diabetes, being a child or adolescent with type 1 diabetes, having had DKA before, having difficulty accessing insulin or diabetes supplies, having other mental health or eating disorder conditions that affect insulin use, and living in circumstances that make regular monitoring difficult. People with type 2 diabetes who are very unwell, or who belong to certain ethnic groups that are more prone to a form of type 2 diabetes with ketones, may also be at higher risk. Having a risk factor does not mean DKA will happen, but it does mean closer attention to blood sugar and ketone monitoring is often advised.

Diabetic ketoacidosis diagnosis

Diabetic ketoacidosis diagnosis is based on a combination of symptoms, physical examination and laboratory tests. Because DKA can worsen quickly, doctors usually begin treatment as soon as it is suspected rather than waiting for every test result.

Tests commonly used to confirm DKA include:

• Blood glucose test. This measures the amount of sugar in the blood. In DKA the level is usually high, often well above the normal range, although in some situations (for example, in people taking SGLT2 inhibitors) it may be only mildly raised.
• Blood ketone test. A blood sample, often from a finger prick, measures a ketone called beta-hydroxybutyrate. High levels support the diagnosis.
• Urine ketone test. A dipstick placed in a urine sample changes color when ketones are present. This is a quicker but less precise test than blood ketones.
• Blood gas analysis. A blood sample is used to measure the acidity (pH) of the blood and the level of bicarbonate, a substance that helps balance acid. In DKA, the pH is low and bicarbonate is reduced.
• Electrolyte panel. This measures salts and minerals such as sodium, potassium and chloride. DKA often disturbs these, and potassium in particular must be watched closely during treatment because it can affect the heart.
• Kidney function tests. Dehydration in DKA can temporarily affect the kidneys, so doctors check creatinine and urea levels.
• Anion gap calculation. Using the electrolyte results, doctors calculate a value that reflects how many unmeasured acids are present in the blood. A high anion gap is typical of DKA.

Doctors generally describe DKA as mild, moderate or severe based on how acidic the blood is and how alert the person is. In addition to confirming DKA, the medical team will look for the trigger. This may involve a chest X-ray, urine culture, blood cultures, an electrocardiogram (ECG, a recording of the heart’s electrical activity) or other tests, depending on the person’s symptoms. Imaging of the abdomen is not usually needed to diagnose DKA itself, but may be ordered if another cause of stomach pain is suspected.

It is important to distinguish DKA from other conditions that can look similar, such as hyperosmolar hyperglycemic state (a different diabetes emergency with very high blood sugar but few ketones), alcoholic ketoacidosis, starvation ketosis and other causes of acidic blood. The laboratory pattern usually allows doctors to tell these apart.

Diabetic ketoacidosis treatment options

Diabetic ketoacidosis treatment options are well established and are delivered in a hospital, often in an emergency department, high-dependency unit or intensive care unit depending on severity. The aims are to correct dehydration, restore insulin, bring blood sugar and ketones down safely, rebalance electrolytes and treat whatever triggered the episode.

The main components of treatment are:

• Intravenous (IV) fluids. Fluids given through a vein replace the large amount of water lost through urination and vomiting. This is usually the first step, because dehydration is often severe and rehydration alone begins to lower blood sugar.
• Insulin therapy. Insulin is typically given as a continuous infusion through a vein, allowing doctors to adjust the dose closely. Insulin switches off ketone production and allows the body to use glucose again. The infusion continues until ketones have cleared and the blood is no longer acidic, not simply until blood sugar looks normal.
• Electrolyte replacement. Potassium is often added to the fluids because insulin moves potassium into the cells and levels can drop dangerously during treatment. Other electrolytes, such as phosphate, may be replaced if needed. Blood tests are repeated frequently, often every one to two hours at first.
• Glucose alongside insulin. As blood sugar falls, doctors often add a sugar-containing fluid so that insulin can continue to clear ketones without causing blood sugar to fall too low.
• Treating the trigger. If an infection is found, antibiotics may be started. If a pump or insulin problem caused the episode, this is corrected. Other medical conditions are treated as needed.
• Monitoring. Heart rhythm, breathing, fluid balance, alertness and laboratory values are watched closely. In children and young adults, doctors are particularly careful about the rate of fluid replacement to reduce the risk of brain swelling, a rare but serious complication.

DKA is not treated with surgery, and there is no procedure or operation for it. Observation alone is never appropriate once DKA is confirmed, because the condition tends to worsen without insulin and fluids. In mild cases, treatment may be completed within a day; moderate and severe cases often require longer hospital stays.

Once ketones have cleared and the person is able to eat and drink, the IV insulin is switched to injected insulin under the skin. There is usually an overlap period so that insulin is never interrupted. Before discharge, the diabetes team commonly reviews insulin doses, monitoring equipment and the plan for managing future illness. Where appropriate, follow-up with an endocrinologist and a diabetes educator is arranged. At Acibadem, this ongoing care is provided through the Endocrinology and Metabolism department. Rehabilitation in the physical sense is rarely needed, although people may feel weak and tired for several days after an episode.

Living with diabetic ketoacidosis and outlook

With prompt hospital treatment, most people recover from an episode of diabetic ketoacidosis. Outcomes tend to be better when the condition is recognized early and when there are no other serious illnesses present. Severe DKA, delayed treatment, very young or older age, and complications such as brain swelling or heart problems are associated with a more difficult course. Because outcomes vary from person to person, no one can promise a specific result, but DKA is generally considered a treatable emergency rather than a condition with lasting damage in itself.

Having had DKA once does not mean it will happen again, but it does signal that something in the balance of insulin, illness and monitoring went wrong. Many people find it helpful to work with their diabetes team afterward to understand the trigger. Common areas reviewed include how to adjust insulin during illness (often called "sick day rules"), when and how to test for ketones, how to check that an insulin pump is working, and what to do if vomiting prevents eating. Having a written plan and a supply of ketone test strips at home is often recommended.

Emotionally, an episode of DKA can be frightening for the person and their family. Some people experience anxiety about it happening again, or feel guilty if a missed dose was involved. These reactions are common, and discussing them with the care team may be useful. For people newly diagnosed with type 1 diabetes through an episode of DKA, there is also a great deal of new information to absorb, and support from diabetes educators is often part of the plan.

Over the longer term, the outlook depends mainly on how well diabetes itself is managed. DKA is one acute complication among several long-term risks associated with diabetes, and steady blood sugar control, regular check-ups and good access to insulin and supplies are the main factors within a person’s influence.

Frequently asked questions

What is diabetic ketoacidosis in simple terms?

Diabetic ketoacidosis is what happens when a person with diabetes does not have enough insulin, so the body burns fat for energy and produces acids called ketones. When ketones build up, the blood becomes acidic and the person becomes dehydrated and unwell. It is a medical emergency that needs hospital treatment with fluids and insulin, and it is different from an ordinary high blood sugar reading.

What are the first diabetic ketoacidosis symptoms to look out for?

The earliest diabetic ketoacidosis symptoms are usually intense thirst, frequent urination and tiredness, often together with high blood sugar readings. As it progresses, nausea, vomiting, stomach pain, fruity-smelling breath, rapid breathing and confusion may develop. If you have diabetes and notice these signs, especially during illness or if you have missed insulin, checking for ketones and seeking medical advice promptly is generally recommended.

What are the most common diabetic ketoacidosis causes?

The most common diabetic ketoacidosis causes are missed or insufficient insulin doses, insulin pump failures, and infections or other illnesses that increase the body’s need for insulin. In people who do not yet know they have diabetes, DKA can be the first sign of type 1 diabetes. Certain medications and severe physical stress such as surgery or a heart attack can also act as triggers in some people.

How is diabetic ketoacidosis diagnosis confirmed?

Diabetic ketoacidosis diagnosis relies on blood tests. Doctors measure blood glucose, blood or urine ketones, and blood acidity through a blood gas test, along with electrolytes such as potassium and bicarbonate. A high glucose level, high ketones and acidic blood together confirm the diagnosis. Further tests, such as cultures, an ECG or a chest X-ray, may be used to find the cause.

What are the diabetic ketoacidosis treatment options?

Diabetic ketoacidosis treatment options center on intravenous fluids to correct dehydration, insulin given through a vein to stop ketone production, and careful replacement of electrolytes, particularly potassium. The underlying trigger, such as an infection, is treated at the same time. There is no surgery or procedure for DKA. Treatment takes place in a hospital with frequent blood tests until ketones clear and the blood is no longer acidic.

Can diabetic ketoacidosis happen in type 2 diabetes?

Yes, although it is less common than in type 1 diabetes. People with type 2 diabetes may develop DKA during severe infections, heart attacks, strokes, surgery or other major physical stress, or in some cases in connection with certain diabetes medications. Some people have a form of type 2 diabetes that is more prone to ketones. Anyone with diabetes who has symptoms of DKA should be assessed urgently regardless of type.

Can diabetic ketoacidosis be prevented?

Many episodes may be prevented by taking insulin as prescribed, never stopping insulin during illness even when not eating, checking blood sugar and ketones more often when unwell, ensuring insulin pumps are working properly, and having a clear plan for sick days agreed with your diabetes team. Prevention is not always possible, particularly when DKA is the first sign of new type 1 diabetes, but early recognition can reduce its severity.

When to see a doctor

If you have diabetes, or if you or your child has symptoms that could suggest undiagnosed diabetes, it is important to know when to seek help. Diabetic ketoacidosis can develop quickly and becomes more dangerous the longer it is untreated. In general, contact your diabetes team or a doctor the same day if your blood sugar stays high despite your usual insulin, if you have moderate ketones on a home test, or if you are unwell with an infection and are unsure how to adjust your insulin.

Seek emergency medical care immediately if any of the following red-flag signs are present:

• Vomiting that prevents you from keeping fluids down, especially with high blood sugar or ketones
• High or rising ketone levels on a blood or urine test
• Rapid, deep or labored breathing, or shortness of breath
• Fruity- or acetone-smelling breath
• Severe abdominal pain
• Confusion, extreme drowsiness, difficulty waking or fainting
• Signs of severe dehydration, such as very dry mouth, sunken eyes, little or no urine, or dizziness when standing
• A child with diabetes who becomes unusually sleepy, irritable or is breathing heavily
• Blood sugar that remains very high and does not respond to correction doses of insulin

If you are unable to reach your diabetes team and any of these signs are present, go to the nearest emergency department or use emergency services. It is safer to be assessed and found not to have DKA than to wait while the condition worsens.