Diabetic ketoacidosis
Summary
Definition
DKA is an acute metabolic complication of diabetes that is potentially fatal and requires prompt medical attention for successful treatment. It is characterised by absolute or relative insulin deficiency and is the most common acute hyperglycaemic complication of type 1 diabetes mellitus.[1][2]
[Figure caption and citation for the preceding image starts]: Triad of DKAAdapted with permission from Kitabchi AE, Wall BM. Diabetic ketoacidosis. Med Clin North Am. 1995;79:9-37. [Citation ends].
This topic covers diabetic ketoacidosis in adults. Bear in mind that people aged 16 to 18 years may be managed by either a paediatric team or an adult medical team according to local arrangements. The 2021 Joint British Diabetes Societies for Inpatient Care guideline recommends following paediatric guidelines if the patient is being managed by a paediatric team, and following adult guidance if they are being managed by an adult team.[2][3]
In the UK, the British Society for Paediatric Endocrinology and Diabetes publishes guidance for the management of DKA in children.[3]
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
Other diagnostic factors
- acetone smell on breath
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
Diagnostic investigations
1st investigations to order
- venous blood gas
- blood ketones
- blood glucose
- urea and electrolytes
- full blood count
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
Treatment algorithm
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.
Differentials
- Hyperosmolar hyperglycaemic state (HHS)
- Lactic acidosis
- Starvation ketosis
More DifferentialsGuidelines
- Type 1 diabetes in adults: diagnosis and management
- The management of diabetic ketoacidosis in adults
More GuidelinesCalculators
Glasgow Coma Scale
Anion Gap
More CalculatorsVideos
Venepuncture and phlebotomy animated demonstration
How to perform an ECG animated demonstration
More videosPatient leaflets
Diabetic ketoacidosis
Diabetes type 2: should I take insulin?
More Patient leaflets
Log in or subscribe to access all of BMJ Best Practice
Use of this content is subject to our disclaimer