Introduction

Diabetic ketoacidosis (DKA) is a serious, potentially life-threatening complication of diabetes. When the body does not have enough insulin to process sugar for energy, the liver will begin to break down fat and produce molecules called ketones for fuel. These ketones accumulate rapidly in the blood, creating a dangerously acidic environment that can make one seriously ill.

Causes of DKA

Our bodies require fuel in order to function. In a healthy individual, the body will use sugar for fuel because it is easy to break down and provides significant amounts of energy. The breakdown of sugar requires a steady supply of insulin—a hormone that allows the sugar in our blood to enter our cells as fuel. Without insulin, sugar cannot leave the bloodstream, leading to high sugar levels in the blood. This process is known as diabetes.

When diabetes prevents the body from using sugar as a fuel source, the liver will begin to rapidly break down fat stores and produce ketones for energy instead. These ketones are produced faster than they can be burned and accumulate at toxic levels in the blood. This ketone accumulation causes the blood to become acidic, resulting in diabetic ketoacidosis.

DKA occurs most often in type I diabetes but can occasionally develop in individuals with advanced type II diabetes.

Events that might trigger DKA include:

• Illness. Being sick and not eating enough food can make diabetes difficult to manage.
• Mismanaged insulin. Missing insulin doses, a clogged insulin pump, or incorrect insulin doses can cause DKA.
• Undiagnosed diabetes. DKA can occur in people who don’t know they have type I diabetes.

Other events such as a heart attack, stroke, surgery, alcohol or drug use, trauma, or medications can trigger DKA.

Signs & Symptoms

Recognizing the early signs of DKA and seeking treatment right away will reduce the risk of developing serious complications. Some of the most common symptoms include:

• Severe thirst and dry mouth
• Frequent urination
• High blood sugar
• Moderate to high levels of ketones in the urine

Later symptoms of DKA, which indicate that the condition is worsening and you need to closely watch for, are:

• Nausea and vomiting
• Fast, deep breathing
• Flushed face
• Fruity-smelling breath
• Headache and fatigue
• Muscle aches or stiffness
• Abdominal pain

The onset of DKA is a medical emergency and must be treated by a trained healthcare provider. If you experience any of the symptoms above, seek medical attention right away.

Complications

When treated early, most individuals with DKA recover within 24-48 hours with little to no long-term effects. If left untreated, DKA can lead to death or severe complications, including kidney failure, brain swelling (encephalopathy), heart attack, coma, stroke, infection, or respiratory failure. Severe complications require longer hospital stays—typically in the ICU—and may result in irreversible organ damage.

Treatment

The goal of DKA treatment is to stop the body’s production of ketones and eliminate excess acid in the blood. This is achieved by reintroducing insulin to the body to slowly lower blood sugar.

Treatment requires close monitoring of vital signs, blood sugar, and other lab values such as electrolytes and blood acid levels (pH). The medical team will provide insulin and IV fluids with supplemental electrolytes to allow a gradual and controlled improvement in lab values. Your doctor may prescribe additional medications if an underlying illness triggered DKA.

If you are vomiting, you will not be allowed to eat or drink anything until your symptoms improve. Continued vomiting will worsen electrolyte imbalances and prolong treatment. Mouth swabs dipped in cold water or an oral moisturizer can help relieve the discomfort of dry mouth.

Safe treatment of DKA must be performed under the supervision of a trained medical team. Do not attempt to treat this condition yourself; doing so can lead to dangerous changes in electrolyte balance.

Prevention

If you have diabetes, it is important to understand the steps you can take to prevent DKA.

• Have a “sick day” plan. Illness and insulin mismanagement is the most common cause of DKA. Talk with your doctor about establishing a medication plan for days when you are sick and not eating as much as usual. If you are vomiting and unable to hold fluids or food, notify your doctor. You may need additional medical support to prevent DKA from occurring.
• Check your blood sugar and urine ketones. Checking blood sugar levels multiple times a day is necessary for the proper management of diabetes. If you notice your blood sugar is unusually high, a quick urine ketone test can help determine if DKA is developing. Ketone tests can be purchased at most major pharmacies. Notify your doctor right away if your blood sugar is higher than normal and you have moderate to high levels of ketones in your urine.
• Take medications as prescribed. Always take your medications as prescribed, even if you are feeling well. If you have an insulin pump, ensure the tubing is free of kinks or clogs, and replace tubing right away if necessary.

Sources

“Diabetic Ketoacidosis.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 25 Mar. 2021, https://www.cdc.gov/diabetes/basics/diabetic-ketoacidosis.html

“Diabetic Ketoacidosis.” MedlinePlus, U.S. National Library of Medicine, 26 Jan. 2020, https://medlineplus.gov/ency/article/000320.htm

“DKA (Ketoacidosis) & Ketones.” American Diabetes Association, https://www.diabetes.org/diabetes/complications/dka-ketoacidosis-ketones