What Is Diabetic Ketoacidosis (DKA)?

In This Article

Diabetic ketoacidosis (DKA) is a dangerous acute condition characterized by hyperglycemia, elevated ketones, and metabolic acidosis. DKA occurs when your body is deprived of glucose for energy and has to rely on ketones instead. This happens when the body does not have enough insulin to transport sugar to the cells for energy.

Elevated levels of ketones can be poisonous to the body because they make the blood acidic. In children and adolescents, DKA represents the most serious acute complication of type 1 diabetes, which usually results in admission to the hospital and is associated with a 0.15–0.3% mortality rate.

DKA can happen to anyone with diabetes, though it is less common in people with type 2 diabetes. Knowing the signs and symptoms of DKA can save a life—without treatment, DKA can lead to cerebral edema, brain damage, coma, and even death.

Checking for diabetic ketoacidosis with ketone meter
 ​OlgaMiltsova / iStock / Getty Images

Diabetic Ketoacidosis Symptoms

Anyone who has diabetes should learn the symptoms of DKA, especially people who have been newly diagnosed with type 1 diabetes. Developing DKA is a warning sign that your blood sugars are too high or that you are getting sick.

It usually starts slowly, but when vomiting occurs it can progress quickly to become a life-threatening condition. Symptoms can range from mild to severe.

Early symptoms include the common symptoms of hyperglycemia:

  • High levels of glucose, blood sugar levels higher than 240 milligrams per deciliter (mg/dL)
  • Excessive thirst or very dry mouth
  • Frequent urination
  • Ketones in the urine which can be mild, moderate, or severe

Later symptoms include:

  • Weight loss often accompanied by excessive hunger
  • Feeling very fatigued
  • Feeling confused or distracted
  • Dry or flushed skin
  • Nausea, vomiting, or abdominal pain (particularly in children)
    (Vomiting can be caused by other illnesses, not just ketoacidosis. If vomiting occurs with other symptoms or lasts for an extended period of time, contact your healthcare provider as soon as possible).
  • Kussmaul respirations: Rapid, shallow breathing or sigh breathing which occurs when the body is trying to get rid of ketones
  • Fruity odor on breath due to exhaled acetone

Causes

Diabetic ketoacidosis occurs when there is little to no insulin in the body. Without insulin the body is unable to use glucose as energy or fuel and then has to rely on fat (ketones).

It can happen to people with type 1 diabetes when doses of insulin do not meet metabolic needs during stress, such as illnesses like pneumonia, trauma, or pancreatitis. It can also occur due to insufficient dosing of insulin, inappropriate use of insulin pumps, or in some instances malfunction of pumps.

Audrey Koltun, Registered Dietitian/Nutritionist at Cohen Children's Medical Center, Division of Pediatric Endocrinology says, "Many of our patients with type 1 diabetes experience DKA due to inadequate insulin dosing.

"This can occur when they do not take insulin while they are eating carbohydrates or when they are not checking blood sugar and forgoing giving insulin when their blood sugars are not at goal (this is called correcting), or both.

"If people already have elevated hemoglobin A1c and they get a cold, the flu, gastroenteritis, infection, or an injury, etc., they can go into DKA from stress."

Koltun also says, "If someone with type 1 diabetes is eating an excessive amount of carbohydrates but taking insulin for them, DKA does not typically occur. Although their blood sugars may not be at goal because they are taking insulin they do not experience DKA."

Many people with type 1 diabetes use an insulin pump to manage their blood sugars. Insulin pumps are devices that deliver small amounts of continuous insulin throughout the day, as well as larger amounts of insulin to cover carbohydrates.

A small cannula is inserted underneath the skin, and a person with diabetes can set their target blood sugars and insulin rates. Some people with diabetes prefer pumps because it frees them from multiple daily injections and allows them to gain tighter control of their blood sugars.

One of the worries about starting pump therapy is that pumps can fail and increase the risk of DKA. Koltun says, "DKA from pump failure does happen, but not as often as DKA from missing insulin. For example, some people stop taking insulin when they are ill since many do not eat much or are unable to eat. This is something you should never do."

There are other reasons someone with diabetes who uses an insulin pump may experience DKA. For example, Koltun notes that if someone is using an insulin pump and is alerted that they have a low reservoir of insulin, then neglecting to change the infusion set can result in DKA.

Other pump malfunctions can include, "A battery that has died, accidental disconnection from an infusion set or pod, a leak in the infusion set or pod, or forgetting to reconnect to a pump after disconnecting," warns Koltun.

To prevent these types of complications standard procedure for starting an insulin pump includes intensive training and people who use an insulin pump should have access to their medical team or trainers when they have questions or concerns.

People who use an insulin pump should also have back up insulin. On the rare occasion that they cannot use their pump, they should be able to inject insulin via a vial or syringe.

When a child starts developing symptoms of type 1 diabetes for the first time, they may be eating and drinking more than normal, which causes a spike in blood sugars because they don't have insulin in their body to compensate.

Parents may not understand why their child is drinking and eating more but losing weight, or why they are wetting the bed when they weren't before. If these symptoms persist for a long time, they can lead to DKA. In fact, many people who are newly diagnosed with diabetes are diagnosed when they are in DKA.

Koltun says, "It seems like some weeks almost all of our newly diagnosed diabetes patients are diagnosed and admitted in DKA. In 2020, almost 80% of the newly diagnosed cases are in DKA, which is much more than usual."

The good news is that understanding the warning signs of type 1 diabetes can help prevent a child from developing DKA at diagnosis.

DKA Can Happen With Type 2 Diabetes

While DKA is less common in people with type 2 diabetes, it can happen. Hyperglycemia in type 2 diabetes was thought to lead only to hyperosmolar hyperglycemic state (HHS) without ketosis.

However, people with type 2 diabetes can develop DKA, particularly if they take insulin to manage their blood sugar. Therefore, people with type 2 diabetes should know the signs and symptoms of DKA, as well as how to manage ketones.

Diagnosis

Because DKA is characterized by hyperglycemia (blood sugar greater than 250 mg/dL), a plasma blood glucose test is warranted. The result typically indicates blood sugars levels much higher than that of 250 mg/dL.

In fact, if blood glucose is checked via meter the meter will often read with the result HIGH, instead of putting out a number. However, most of the time these values are measured via a blood draw.

If a child presents to the hospital with suspected DKA, diagnosis will be confirmed by detection of hyperketonemia (ketones in the blood) as well as ketones in the urine (ketonuria).

Other measures will confirm the diagnosis, such as a bicarbonate level less than 18 mEq/L, and a pH less than 7.30. Serum electrolytes, blood urea nitrogen (BUN), creatinine, and osmolarity should be measured.

Treatment

Treatment for DKA takes place in the hospital and requires correction of high blood sugar and acidosis, volume repletion, and prevention of hypokalemia (low potassium).

Volume Repletion

Water deficits will be corrected to restore fluid that has been lost via urine. Saline infusion will be delivered intravenously. Intravenous fluids will also help to raise blood pressure. Depending on the degree of dehydration, fluids will be delivered slowly until blood pressure and urine output is stable.

Correction of Hyperglycemia and Acidosis

Hyperglycemia is corrected by giving regular insulin 0.1 unit/kg IV bolus initially, followed by continuous IV infusion of 0.1 unit/kg/h in 0.9% saline solution. Physicians will monitor ketone clearance, as well as serum pH and bicarbonate.

When blood glucose levels drop, a small amount of dextrose is added to prevent low blood sugar. Insulin adjustments continue to be made once a person is able to eat and blood sugar begin to stabilize.

Hypokalemia Prevention

As sugar is carried away in the urine, water, salt and potassium are drawn into the urine. Electrolytes such as potassium play a critical role in cell function.

Hypokalemia (low levels of potassium) prevention may require potassium replacement, which is placed in the IV fluids. These levels will continue to be checked hourly or every other hour during the initial stages of treatment.

Other Measures

Hypophosphatemia often develops during treatment of DKA, but phosphate repletion is of unclear benefit in most cases. If indicated potassium phosphate can be infused over six to 12 hours.

If potassium phosphate is given, the serum calcium level usually decreases and should be monitored. Correction of acid-base balance will occur. Management of concurrent infection (if present) is also part of the treatment regimen.

Prognosis

With prompt treatment, more than 95% of patients recover from diabetic ketoacidosis. Overall mortality rates for diabetic ketoacidosis are less than 1%; however, mortality is higher in the elderly and in patients with other life-threatening illnesses. Shock or coma on admission indicates a worse prognosis.

For those people who experience repeated episodes of DKA annually, there appears to be an increase in mortality. Researchers have identified certain factors associated with repetitive DKA. These include lack of adherence to therapy, low socioeconomic status, substance abuse, and low education, as well as those people receiving care across multiple health systems, leading to added difficulties in long-term continuity and coordination of care.

This study was conducted on a select population that may not translate to all populations, however, it is important to note that for these types of patients, further research is needed on potential interventions.

Prevention

If you are someone with diabetes or are a caretaker of a child with type 1 diabetes, it's important to develop a sick day plan with your medical team.

Illness can cause blood sugars to spike to due hormones that are secreted during illness such as cortisol and adrenaline. Understanding your insulin needs during times of illness can help to prevent high blood sugars which can trigger ketoacidosis.

In addition, knowing how to check for ketones and what to do with the information will be important, as acting quickly can prevent a serious situation. Having back up supplies, such as extra insulin, is another important step in preventing ketoacidosis.

All people with diabetes should have a medic alert—whether it be a bracelet or a necklace. In the event of an emergency, you want people to be able to identify that you have diabetes. Lastly, always make sure you have a way to reach your medical team at any time of day or night.

Continuous Glucose Monitor

A continuous glucose monitor (CGM) can help alert people with diabetes as to when their blood sugars are trending up or down.

Koltun says, "Most of the children are put on CGMs soon after diagnosis. Many of the newer CGMs can be used to replace manual finger stick blood sugar checks, which can lessen the burden of diabetes in our pediatric population. For this reason CGMs are a diabetes technology that has changed the way diabetes is managed."

Parents of children with type 1 diabetes should be cautious in how they use CGMs. Koltun cautions, "It's important to try not to become obsessed with the numbers. Micromanaging diabetes based on sensor readings can be problematic. For example, giving a correction dose of insulin based on a sensor reading before the insulin has a chance to work can result in hypoglycemia."

But, CGMs can help parents feel less worried about blood sugars in young children, particularly overnight or when they are sick. Parents are able to set alerts so that they can know when a blood sugar is trending up or down and take appropriate action.

Check for Ketones

Checking for ketones is a simple process and can be life-saving. You can check for ketones with a urine test. You can also use a small sample of blood to test for ketones.

Koltun says, "Blood ketone meters are much more accurate in detecting ketones than urine ketone strips. The blood ketone meter can detect ketones before they show up in the urine. However, some insurance companies do not cover the strips which can be costly. Urine ketone strips can be purchased easily at a pharmacy and are not too expensive."

When you are ill, it is advisable to check for ketones every four to six hours and when your blood sugar is more than 240 mg/dl. It is also advisable to check for ketones if you have any symptoms of ketoacidosis.

Your sick day plan should give you guidelines on how to handle low, moderate, and high ketones. However, it is always a good idea to contact your medical team whenever you are in doubt of how to react.

The American Diabetes Association says to check for ketones when blood glucose is greater than 240 one time and also when someone is ill. Koltun says, "For those patients on multiple daily injections, if blood glucose is greater than 250 mg/dl two or more consecutive times, check for ketones. If ketones are moderate to large, drink ample amounts of sugar-free liquids and call your medical team as soon as possible."

She notes that the protocol for insulin pump users is different in her office. For those on an insulin pump, "We teach our families to check for ketones if the blood glucose or sensor glucose is above 250 mg/dl (even once) for no obvious reason. If ketones are trace or small then give a correction dose via insulin pump and recheck in one hour.

"If blood glucose or sensor glucose are not coming down, change pump site. Re-check blood ketones in one to two hours. If they do not have a blood ketone meter, then check for urine ketones at the next void. We encourage drinking lots of water or unsweetened beverages such as Diet Snapple or Crystal Light."

Koltun advises, "If blood ketones are moderate to large, drink plenty of sugar-free liquids and call our office right away for instructions on giving a 'ketone dose' via syringe or insulin pen. The pump site will need to be changed."

Also, check ketones if blood glucose is greater than 250 and you plan on exercising. It's important to never exercise when you have ketones or when your blood sugar is greater than 240 mg/dl. Exercising when you have ketones can increase blood sugar and ketones and therefore is not advisable.

Continue Insulin When Sick

Do not stop taking your insulin even if you are sick and not eating. Symptoms of a stomach virus or other illnesses can mimic the symptoms of DKA. Never stop taking insulin when you are sick even if you are not eating.

Insulin needs often increase during illness due to hormones such as cortisol. If you are unsure how to take care of your diabetes when you are sick make sure to call your medical team.

Educate Children in Self-Management

If your child is starting to manage their diabetes on their own and they are having trouble with insulin dosing or managing their blood sugars, you can always make an appointment with your medical team for reevaluation and education.

Make sure they understand when and how to check for ketones. In the event that they are not with you and are not feeling well you want to feel safe knowing that

Coping

Upon diagnosis, most families will be visited by a social worker in the hospital so that they may address the emotional and mental aspects of having to go through a DKA episode. These professionals can provide on-going resources and support to cope not only with DKA, but with a type 1 diabetes diagnosis.

Since diabetes is a disease that is managed daily, health professionals are aware of the burden it can cause on families diagnosed with it. In addition to a social worker, children with type 1 diabetes will be likely be seen by a registered dietitian, certified diabetes care and education specialist, as well as an endocrinologist. This team of professionals can help guide and educate the family on all things diabetes-related.

Organizations such as the Juvenile Diabetes Research Foundation offer ways to get involved in the diabetes community, such as one-on-one support, community forum, and a wealth of additional resources and support.

DKA Is Not Keto

Diabetic ketoacidosis is not the same as “keto” used for weight loss and some types 2 diabetes management. Unlike ketoacidosis, ketosis means that your body is using fat for fuel and can result in ketones that reach maximum levels of about 7/8 mmol/l with no change in pH.

During ketosis, it is suggested that ketones do not exceed these levels because the brain is able to use the ketones for fuel in place of glucose. During ketoacidosis, the blood pH is lowered and ketones in the blood can exceed 20 mmol/l. Ketoacidosis can become life-threatening when not treated.

If done properly and under supervision, some people with type 2 diabetes (unless they have kidney issues or established heart disease) can safely follow a ketogenic diet. Keep in mind that it takes a lot of work, dedication, meal planning, and monitoring.

People with type 1 diabetes should not follow a ketogenic diet. Always discuss with your healthcare professional before starting any new dietary regimen. 

A Word From Verywell

Diabetic ketoacidosis (DKA) is a serious condition that can be life-threatening if not treated promptly. All people with diabetes should know the warning signs of DKA so that they can aim to prevent serious side effects and prevent hospitalization. Make sure you understand your emergency plan and how to contact your medical team when necessary.

In addition, it's important to know when and how to check for ketones. Should you or your child develop DKA due to a newly diabetes diagnosis, know that you not alone and that you'll be supported and provided with the tools you need to live a healthy life with diabetes.

Remember that just because you or your child have diabetes, doesn't mean a cold, illness, or injury will send them into DKA. DKA most commonly occurs when insulin is omitted or needs are not met.

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