Diabetic Ketoacidosis

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Diabetic Ketoacidosis

In diabetes, blood glucose is not able to reach the body cells where it can be utilized to produce energy. In such cases, the cells start to break down fat to produce energy. This process produces a chemical called ketone.[1] The buildup of ketones makes the blood more acidic. When the blood ketone level gets too high, a condition develops called diabetic ketoacidosis (DKA). It is a serious condition that can lead to coma or even death. DKA can happen to anyone with diabetes though it is more common in people with type 1 diabetes.[2] In this article, we’ll explore the causes, symptoms treatment options, and complications of this life-threatening condition.

Causes of Diabetic Ketoacidosis

DKA results from inadequate insulin levels that cause the cells to burn fat for energy. Ketones are released into the blood when fats are broken down. In people with diabetes, an underlying problem often triggers the onset of DKA. The following problems or conditions may contribute to DKA:

  • An illness where the body produces higher levels of stress hormones like cortisol or adrenalin; these illnesses have a countereffect on the action of insulin (conditions like pneumonia or a urinary tract infection are common culprits)
  • Inadequate insulin due to missed doses or more requirements
  • Alcohol or drug abuse
  • Less food intake (this could be caused by sickness, fasting, or an eating disorder; bulimia, for example, produces excess ketones)
  • Medications like corticosteroids and diuretics
  • Pregnancy
  • Heart attack [3],[4]

Symptoms of Diabetic Ketoacidosis

Symptoms of DKA typically evolve over a period of 24 hours. Some symptoms to be aware of include the following:

  • Nausea and vomiting
  • Polyuria (frequent urination)
  • Excessive thirst
  • Abdominal pain
  • Fatigue and confusion
  • Fruity-scented breath
  • Long, deep labored breathing (affected person may be gasping for breath)
  • Low blood pressure[3], [4], [5], [6]

Check your blood glucose levels if you develop these symptoms. If your blood glucose levels are above 240mg/dl (13.3mmol/L), check for ketone levels using a blood or urine ketone testing kit.[2], [3]

These are some basic guidelines to consider when taking a blood ketone test:

  • Level of ketones in the range of 0.6-1.5mmol/L: you are at a slightly increased risk of developing DKA. A retest should be done in a couple of hours.
  • Level of ketones in the range of 1.6 – 2.9mmol/L: you are at a moderately increased risk of DKA and should contact a physician.
  • Level of ketones at or above 3mmol/L: you are at a very high risk of DKA and you should get medical help immediately.

This is the basic guideline to consider when taking a urine ketone test:

If the urine ketone levels show a result of more than 2+, there is a high chance you have DKA and should seek medical help.[3], [7]

Other methods of ketone testing include:

  • Arterial blood gas
  • Basic metabolic panel (blood tests to measure sodium and potassium levels, as well as blood and kidney tests)
  • Blood glucose test
  • Blood pressure measurement[8], [9]

If you find that your blood glucose levels and blood/urine ketone levels are high, please contact your doctor. Your doctor may recommend that you visit the closest medical/emergency care facility.

There are some steps you can take to bring down ketone levels in your body:

  • Drink excess water to flush out ketones from your body.
  • Keep testing your blood sugar every 3-4 hours.
  • Avoid exercising until your blood glucose and ketone levels drop to normal.[7]

Treatment of Diabetic Ketoacidosis

The primary aim of treating DKA is to replace the lost fluids and electrolytes in your body. Here are the most common ways that DKA is treated in the hospital:

  • Fluid replacement The amount of fluid replenishment depends on the degree of dehydration. If dehydration is severe, then rapid infusion of saline (adults – 1L, children -10ml/kg) is recommended. If DKA is moderate, then saline is infused at a slower rate. A mild case of DKA requires replenishment with oral rehydration.[10], [11], [12]
  • Insulin therapy Insulin is generally given through IV in the hospital at a rate of 0.1unit/kg/hr. When your blood glucose levels fall below 240mg/dl, IV insulin should be stopped. Potassium (K+) levels should be maintained at or above 3.3mmol/L as insulin lowers the amount of this mineral in the body. In addition to this treatment, your heart rate should monitored constantly.[12], [13]
  • Electrolyte replacement Insulin therapy lowers the level of blood electrolytes, hence they need to be replenished either through IV or oral rehydration.[13]

Before leaving the hospital, be sure to discuss the steps to prevent DKA with your doctor in detail. He or she will likely recommend the following prevention measures for you:

  • Monitor your blood sugar at least 3-4 times a day or more during times of illness or stress.
  • Follow your insulin treatment plan.
  • Take extra care when you are sick and follow the sick day steps discussed with your doctor.
  • Check your ketone level.
  • Keep your diabetes in check by avoiding the potential causes of DKA (mentioned above). [4]

Complications of Diabetic Ketoacidosis

Although the early signs and symptoms of DKA can often be treated through self-care measures or a trip to the hospital, there are some cases in which other complications may develop. Some of these complications are listed below:

  • Hyperkalemia and hypokalemia (electrolyte disorders) Severe increases and decreases in the K+ levels during DKA occurrence and treatment can be life-threatening. Therefore, careful monitoring of K+ is essential. Severe dehydration leads to acute pre-renal failure (liver failure) and an increase in K+ If the increase is above 5.5mmol/L, its infusion along with saline is discouraged. Treatment with fluids and electrolytes leads to a decrease in the K+; if the fall is below 5.5mmol/L, then reinfusion with K+ levels should be done.
  • Hypoglycemia (low blood sugar) In this complication, blood glucose levels fall as ketoacidosis is corrected through treatment. In severe cases, hypoglycemia leads to cardiac arrhythmias, brain injury, and even death. IV glucose is given when blood sugar levels fall below 14mmol/L.
  • Cerebral Edema (swelling of the brain caused by excess fluid) It is the most dangerous complication of DKA, occurring sub-clinically both before and after treatment. It may be due to cerebral hypoperfusion (insufficient blood flow to the brain, which cuts off oxygen supply) with subsequent reperfusion. This critical, life-threatening complication is more common in children than adults.
  • Pulmonary edema (excess fluid in the lungs) A rare complication associated with the treatment of DKA. Elderly patients with impaired cardiac function are at a greater risk. [9], [8], [14]

You’ve learned about the causes, symptoms, treatments, and possible complications of DKA. For more information about how to manage your type 1 or type 2 diabetes in an effort to prevent this condition from occurring, check out the latest information at dlife.com.


[1] “What is Diabetes? | NIDDK.” [Online]. Available: https://www.niddk.nih.gov/health-information/diabetes/overview/what-is-diabetes. [Accessed: 23-Jan-2018].

[2] “DKA (Ketoacidosis) & Ketones: American Diabetes Association®.” [Online]. Available: http://www.diabetes.org/living-with-diabetes/complications/ketoacidosis-dka.html?referrer=https://www.google.com/. [Accessed: 23-Jan-2018].

[3] “Diabetic ketoacidosis – NHS.UK.” [Online]. Available: https://www.nhs.uk/conditions/diabetic-ketoacidosis/. [Accessed: 24-Jan-2018].

[4] “Diabetic ketoacidosis – Symptoms and causes – Mayo Clinic.” [Online]. Available: https://www.mayoclinic.org/diseases-conditions/diabetic-ketoacidosis/symptoms-causes/syc-20371551. [Accessed: 24-Jan-2018].

[5] G. E. Umpierrez, D. Smiley, and A. E. Kitabchi, “Narrative review: ketosis-prone type 2 diabetes mellitus.,” Ann. Intern. Med., vol. 144, no. 5, pp. 350–7, Mar. 2006.

[6] M. S. Eledrisi, M. S. Alshanti, M. F. Shah, B. Brolosy, and N. Jaha, “Overview of the diagnosis and management of diabetic ketoacidosis.,” Am. J. Med. Sci., vol. 331, no. 5, pp. 243–51, May 2006.

[7] “Ketones: What is A Ketone Urine Test, High vs. Low, Normal Levels.” [Online]. Available: https://www.webmd.com/diabetes/ketones-and-their-tests#3. [Accessed: 24-Jan-2018].

[8] D. P. Westerberg, “Diabetic ketoacidosis: evaluation and treatment.,” Am. Fam. Physician, vol. 87, no. 5, pp. 337–46, Mar. 2013.

[9] M. W. Savage, K. K. Dhatariya, A. Kilvert, G. Rayman, J. A. E. Rees, C. H. Courtney, L. Hilton, P. H. Dyer, and M. S. Hamersley, “Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis,” Diabet. Med., vol. 28, no. 5, pp. 508–515, May 2011.

[10] “Type 1 diabetes in adults: diagnosis and management | Guidance and guidelines | NICE.”

[11] “Wayback Machine.” [Online]. Available: https://web.archive.org/web/20111027082817/http://www.bsped.org.uk/professional/guidelines/docs/DKAGuideline.pdf. [Accessed: 24-Jan-2018].

[12] A. E. Kitabchi, G. E. Umpierrez, J. M. Miles, J. N. Fisher, R. A. Kreisberg, J. I. Malone, and B. M. Wall, “Hyperglycemic crises in adult patients with diabetes.,” Diabetes Care, vol. 32, no. 7, pp. 1335–43, Jul. 2009.

[13] “Diabetic ketoacidosis – Diagnosis and treatment – Mayo Clinic.” [Online]. Available: https://www.mayoclinic.org/diseases-conditions/diabetic-ketoacidosis/diagnosis-treatment/drc-20371555. [Accessed: 24-Jan-2018].

[14] “Standards of Medical Care in Diabetes-2016: Summary of Revisions.,” Diabetes Care, vol. 39 Suppl 1, pp. S4-5, Jan. 2016.

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