Diabetic Ketoacidosis (DKA)

What happens in DKA

Insulin lets cells take in glucose. Without enough insulin, cells starve even though blood sugar is high. The body responds by breaking down fat, and the liver turns the fatty acids into ketones (mainly beta-hydroxybutyrate and acetoacetate). Small amounts are harmless. Large amounts make the blood acidic.

Three problems happen at once:

1. High blood sugar (hyperglycemia): usually above 250 mg/dL (13.9 mmol/L), though not always.
2. Ketosis: blood ketones of 3.0 mmol/L or more.
3. Acidosis: blood pH below 7.30 or a low bicarbonate level.

High sugar spills into the urine and pulls water with it, so you can lose 5 to 7 liters of fluid (11 to 15 lb of body water) and large amounts of potassium. The dehydration and acid together cause most of the symptoms.

DKA symptoms and warning signs

Early signs, usually over several hours:

• extreme thirst and a dry mouth
• passing large amounts of urine
• high blood sugar readings and positive ketones
• tiredness and blurred vision

Later signs, as acid builds:

• nausea, vomiting and belly pain, sometimes severe enough to mimic appendicitis
• deep, sighing, rapid breathing (Kussmaul breathing), which is the body trying to blow off acid
• breath that smells fruity or like nail polish remover (acetone)
• a fast heartbeat, dizziness on standing and cold hands
• confusion, drowsiness and, if untreated, coma

In children, DKA can be mistaken for gastroenteritis or a chest infection. Vomiting without diarrhea plus heavy breathing in a child who has been drinking and peeing a lot should prompt a finger-prick glucose test.

What causes DKA

DKA in type 2 diabetes

DKA is less common in type 2 diabetes because some insulin is still produced, but it happens during severe illness, with SGLT2 inhibitors, and in "ketosis-prone" type 2 diabetes, which is more common in people of African and Hispanic descent. Some adults labeled type 2 actually have slowly progressive autoimmune diabetes (LADA).

Euglycemic DKA

In euglycemic DKA the blood sugar is below 250 mg/dL (13.9 mmol/L) but ketones and acid are high. It is linked to SGLT2 inhibitors, pregnancy, fasting, low-carbohydrate diets and alcohol. Because the meter reading looks reassuring, it is easily missed. If you take an SGLT2 inhibitor and feel sick, check ketones, not just glucose.

DKA vs other high-sugar and ketone states

Hyperosmolar hyperglycemic state and alcoholic ketoacidosis are covered on their own pages. DKA is one type of metabolic acidosis.

How DKA is diagnosed

In the ER, doctors check:

• Finger-prick or lab glucose
• Blood ketones (beta-hydroxybutyrate). This is more accurate than urine ketones, which lag behind and measure a different ketone.
• Venous blood gas: pH and bicarbonate show how acidic the blood is. Severity is graded mild, moderate or severe based on pH (below 7.30, 7.24, and 7.00 or lower) and mental state.
• Electrolytes: sodium, potassium and the anion gap. Potassium may read normal or high even though total body stores are low.
• Kidney function, a blood count and tests for the trigger: urine culture, chest X-ray, ECG, lipase, pregnancy test and sometimes troponin.

DKA treatment

DKA is treated in the hospital, often in a high-dependency or intensive care unit. Treatment follows a protocol with hourly checks.

1. IV fluids: saline or a balanced crystalloid restores circulation and dilutes the sugar. Fluids alone lower glucose noticeably. Children receive fluid more cautiously because of the risk of brain swelling.
2. IV insulin: a continuous, weight-based infusion switches off ketone production. Long-acting insulin is often continued alongside it.
3. Potassium: insulin drives potassium into cells, so levels can fall dangerously. Potassium is added to the drip and checked every 1 to 2 hours. Insulin is delayed if potassium starts very low.
4. Glucose: once sugar falls below about 250 mg/dL (13.9 mmol/L), dextrose is added so insulin can keep clearing ketones without causing hypoglycemia.
5. Treat the cause: antibiotics for infection, a new pump set, stopping SGLT2 inhibitors.

DKA is considered resolved when ketones fall below 0.6 mmol/L and pH is above 7.30. You then switch back to injected or pump insulin, overlapping by 1 to 2 hours so ketones do not rebound. Most adults recover within 24 to 48 hours.

Mild DKA in some settings may be managed with subcutaneous rapid-acting insulin instead of an IV drip, but only under medical supervision.

Complications

• Low potassium (hypokalemia), which can cause dangerous heart rhythms.
• Low blood sugar during treatment.
• Cerebral edema (brain swelling): rare but the leading cause of death from DKA in children. Headache, slowing heart rate, rising blood pressure or worsening drowsiness during treatment are warning signs. See cerebral edema.
• Acute kidney injury from dehydration.
• Blood clots and, rarely, fluid in the lungs.

Death from DKA is uncommon in hospitals with good care (under 1% in many high-income countries) but rises with age, delayed treatment and serious underlying illness.

Preventing DKA: sick-day rules

• Never stop basal insulin, even if you are not eating. You may need more insulin when ill.
• Check glucose and ketones every 2 to 4 hours when unwell or when sugar is above 250 mg/dL (13.9 mmol/L). Keep in-date ketone strips at home.
• Drink sugar-free fluids regularly, about 100 ml (3 to 4 oz) an hour for adults. If you cannot eat, sip carbohydrate-containing drinks and keep taking insulin.
• Pump users: if sugar is unexplainedly high, give a correction dose by pen or syringe and change the whole set.
• SGLT2 inhibitors: pause them during acute illness, before surgery and during prolonged fasting, as your clinician advises.
• Seek help early if vomiting, if ketones are 1.5 mmol/L or higher and not falling, or if you are unsure.

Recognizing new type 1 diabetes early (thirst, urination, weight loss, bedwetting in a previously dry child) prevents many DKA cases at diagnosis.

Frequently asked questions

What are the first signs of diabetic ketoacidosis?

The earliest signs are high blood sugar readings, extreme thirst, passing lots of urine and feeling tired. Nausea, vomiting, belly pain, fruity breath and deep, fast breathing follow as ketones build. A blood ketone reading of 1.5 mmol/L or higher with high sugar means DKA may be developing and you need to act.

What ketone level is dangerous?

On a blood ketone meter, under 0.6 mmol/L is normal, 0.6 to 1.4 mmol/L is raised and needs extra insulin and fluids, 1.5 to 2.9 mmol/L carries a high risk of DKA, and 3.0 mmol/L or higher needs emergency care. On urine strips, "moderate" or "large" ketones with high sugar call for urgent advice.

Can you have DKA with normal blood sugar?

Yes. Euglycemic DKA happens with blood sugar below 250 mg/dL (13.9 mmol/L). It is most often linked to SGLT2 inhibitor medicines, pregnancy, fasting, very low-carbohydrate diets and heavy drinking. Anyone at risk who feels sick should test for ketones rather than relying on the glucose reading.

How long does it take to recover from DKA?

Most adults have their DKA resolved within 24 to 48 hours of starting hospital treatment and go home in 2 to 4 days. Tiredness can last a week or more. Recovery takes longer if a serious infection or other illness triggered the episode.

Can people with type 2 diabetes get DKA?

Yes, though it is less common than in type 1. It occurs during severe infections or other illness, with SGLT2 inhibitor medicines, and in ketosis-prone diabetes. Some people diagnosed with type 2 diabetes actually have slowly developing autoimmune diabetes, which raises the risk.

Is DKA the same as ketosis on a keto diet?

No. Nutritional ketosis on a low-carbohydrate diet usually keeps blood ketones between about 0.5 and 3.0 mmol/L with normal blood sugar and normal blood acidity. DKA involves much higher ketones, acidic blood and usually high sugar, because insulin is missing.