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Diabetic ketoacidosis

Background knowledge 🧠


  • Diabetic ketoacidosis (DKA) is a serious, potentially life-threatening complication of diabetes mellitus
  • Characterized by hyperglycemia, ketosis, and metabolic acidosis
  • Occurs primarily in type 1 diabetes mellitus but can also occur in type 2
  • Requires urgent medical treatment


  • Incidence: higher in type 1 diabetes mellitus
  • DKA is a common initial presentation in newly diagnosed type 1 diabetes
  • Can occur at any age but more common in younger patients
  • Increased risk in patients with poor glycemic control or those who miss insulin doses
  • Mortality rate has decreased with improved treatment protocols

Aetiology and Pathophysiology

  • Absolute or relative insulin deficiency
  • Increased counter-regulatory hormones (glucagon, cortisol, catecholamines)
  • Triggers: infection, stress, inadequate insulin therapy, myocardial infarction, trauma
  • Pathophysiology: insulin deficiency leads to increased lipolysis, releasing free fatty acids
  • Ketogenesis in the liver produces ketone bodies (beta-hydroxybutyrate, acetoacetate)
  • Accumulation of ketone bodies leads to metabolic acidosis

Clinical Features 🌑️


  • Polyuria (frequent urination)
  • Polydipsia (excessive thirst)
  • Nausea and vomiting
  • Abdominal pain
  • Fatigue and weakness
  • Altered mental status (confusion, drowsiness)
  • Symptoms of underlying infection (if present)
  • Weight loss
  • Dehydration symptoms (dry mouth, skin)


  • Tachycardia
  • Hypotension
  • Kussmaul respirations (deep, labored breathing)
  • Fruity breath odor (acetone)
  • Dehydration signs (dry mucous membranes, reduced skin turgor)
  • Altered consciousness (lethargy, coma)
  • Abdominal tenderness
  • Signs of infection (fever, cough, etc.)
  • Hyperglycemia (blood glucose > 11 mmol/L)
  • Ketosis (positive urine or serum ketones)
  • Metabolic acidosis (low bicarbonate, pH < 7.3)

Investigations πŸ§ͺ


  • Blood glucose levels (typically > 11 mmol/L)
  • Serum ketones (beta-hydroxybutyrate)
  • Arterial blood gases (metabolic acidosis)
  • Electrolytes (hyperkalemia, hyponatremia)
  • Urinalysis (glucosuria, ketonuria)
  • Renal function tests (creatinine, urea)
  • Complete blood count (leukocytosis)
  • Infection screen (blood cultures, chest X-ray)
  • ECG (to detect hyperkalemia effects)
  • Plasma osmolality

Diagnostic criteria

  • Glucose >11mmol/L (NB. glucose may be normal in some circumstances – β€˜euglycaemic DKA’, e.g. if taken insulin recently, on SGLT-2 inhibitor, during pregnancy)
  • pH <7.3 or HCO3– <15mmol/L
  • Capillary ketones >3mmol/L (or ++ urinary ketones)

Management πŸ₯Ό


  • Fluid replacement (IV 0.9% saline)
  • Insulin therapy (fixed rateIV insulin infusion)
  • Electrolyte management (potassium replacement)
  • Monitoring of blood glucose and electrolytes
  • Address underlying cause (e.g., antibiotics for infection)

Learn more here.


  • Cerebral edema
  • Hypokalemia
  • Hypoglycemia (from overcorrection)
  • Acute respiratory distress syndrome (ARDS)
  • Acute kidney injury
  • Thromboembolism
  • Infections
  • Death (if untreated or severe)


  • Good with prompt and appropriate treatment
  • Mortality rate < 1% with proper management
  • Higher risk in elderly and those with comorbid conditions
  • Long-term prognosis depends on overall diabetes management
  • Regular follow-up and patient education reduce recurrence

Key Points

  • DKA is a medical emergency requiring prompt treatment
  • Characterized by hyperglycemia, ketosis, and metabolic acidosis
  • Management includes fluids, insulin, and electrolyte replacement
  • Early recognition and treatment are crucial to prevent complications
  • Follow local guidelines for management (e.g., NICE guidelines)
  • Patient education is essential to prevent recurrence

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