Diabetic ketoacidosis

Last reviewed: 6 Nov 2022
Last updated: 18 Nov 2022

Summary

Definition

History and exam

Key diagnostic factors

  • known diabetes or features of diabetes
  • nausea and/or vomiting
  • abdominal pain
  • dehydration
  • hyperventilation
  • reduced consciousness
  • presence of risk factors
  • hypothermia
Full details

Other diagnostic factors

  • acetone smell on breath
Full details

Risk factors

  • inadequate or inappropriate insulin therapy
  • infection
  • myocardial infarction
  • pancreatitis
  • stroke
  • acromegaly
  • hyperthyroidism
  • drugs (e.g., corticosteroids, thiazides, pentamidine, sympathomimetics, second-generation antipsychotics, cocaine, immune checkpoint inhibitors, or SGLT2 inhibitors)
  • Cushing's syndrome
  • Hispanic or black ancestry
  • bariatric surgery
Full details

Diagnostic investigations

1st investigations to order

  • venous blood gas
  • blood ketones
  • blood glucose
  • urea and electrolytes
  • full blood count
Full details

Investigations to consider

  • urinalysis
  • ECG
  • pregnancy test
  • amylase and lipase
  • cardiac enzymes
  • creatinine kinase
  • chest x-ray
  • liver function tests
  • blood, urine, and sputum cultures
Full details

Treatment algorithm

ACUTE

initial systolic blood pressure <90 mmHg

initial systolic blood pressure ≥90 mmHg

Contributors

Expert advisers

Gerry Rayman, MD, FRCP

Consultant Physician and Head of Service

Diabetes and Endocrine Centre and the Diabetes Research Unit

Ipswich Hospitals NHS Trust

Ipswich

UK

Biography

GR is Lead and Innovator of the National Inpatient Diabetes Audit; and Joint Clinical Lead of the Diabetes, Getting It Right First Time programme.

Disclosures

GR has been paid for advisory board meetings with the following companies: Sanofi Aventis, Abbott Diabetes UK, Lilly Diabetes, and Bayer. GR has received lecture fees from Sanofi Aventis, Abbott Diabetes UK, Lilly Diabetes, Novo Nordisk, and Napp Pharmaceuticals Ltd.

Acknowledgements

BMJ Best Practice would like to gratefully acknowledge the previous team of expert contributors, whose work has been retained in parts of the content:

Aidar R. Gosmanov, MD, PhD, FACE

Associate Professor of Medicine

Division of Endocrinology

Albany Medical College

Chief, Endocrinology Section

Albany VAMC

Albany

NY

Laleh Razavi Nematollahi, MD

Assistant Professor of Medicine

Case Western Reserve University

Cleveland

OH

Disclosures

ARG and LRN declare that they have no competing interests.

Peer reviewers

Edward Jude, MD, MRCP

Consultant Diabetologist and Endocrinologist

Tameside and Glossop Integrated Care NHS Foundation Trust

Honorary Professor, University of Manchester

Honorary Professor, Manchester Metropolitan University Manchester

UK

Disclosures

EJ declares that he has no competing interests.

Ketan Dhatariya, MBBS, MSc, MD, MS, FRCP, PhD

Honorary Professor of Medicine

Norwich Medical School, University of East Anglia

Consultant Diabetes & Endocrinology

Norfolk and Norwich University Hospitals NHS Foundation Trust

Norwich

UK

Disclosures

KD is the chair of the Joint British Diabetes Societies for Inpatient Care. KD has received honoraria from Diabetes Professional Care to speak at its annual meeting about these guidelines. No other reimbursement has been received from commercial organisations with respect to these guidelines. KD has helped to develop educational materials on this subject for the European Association for the Study of Diabetes, but did not receive any reimbursement. For other work as the chair of JBDS, KD has received honoraria from Lilly for developing educational material.

Editors

Annabel Sidwell

Section Editor, BMJ Best Practice

Disclosures

AS declares that she has no competing interests.

Luisa Dillner

Head of Research and Development, BMJ

Disclosures

LD declares that she has no competing interests.

Anna Ellis

Head of Editorial, BMJ Best Practice

Disclosures

AE declares that she has no competing interests.

Rachel Wheeler

Lead Section Editor, BMJ Best Practice

Disclosures

RW declares that she has no competing interests.

Julie Costello

Comorbidities Editor, BMJ Best Practice

Disclosures

JC declares that she has no competing interests.

Adam Mitchell

Drug Editor, BMJ Best Practice

Disclosures

AM declares that he has no competing interests.

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