Diabetic ketoacidosis (DKA) is characterised by a biochemical triad of hyperglycaemia (or a history of diabetes), ketonaemia, and metabolic acidosis, with rapid symptom onset.
Common symptoms and signs include increased thirst, polyuria, weight loss, excessive tiredness, nausea, vomiting, dehydration, abdominal pain, hyperventilation, and reduced consciousness.
Successful treatment includes correction of volume depletion, ketogenesis, hyperglycaemia, electrolyte imbalances, and comorbid precipitating events, with frequent monitoring.
Complications of treatment include hypoglycaemia, hypokalaemia, pulmonary oedema, and acute respiratory distress syndrome.
Cerebral oedema, a rare but potentially rapidly fatal complication, occurs mainly in children. It may be prevented by avoiding overly rapid fluid and electrolyte replacement.
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.
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.
In the UK, the British Society for Paediatric Endocrinology and Diabetes publishes guidance for the management of DKA in children.
History and exam
Key diagnostic factors
- known diabetes or features of diabetes
- nausea and/or vomiting
- abdominal pain
- reduced consciousness
- presence of risk factors
Other diagnostic factors
- acetone smell on breath
- inadequate or inappropriate insulin therapy
- myocardial infarction
- 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
1st investigations to order
- venous blood gas
- blood ketones
- blood glucose
- urea and electrolytes
- full blood count
Investigations to consider
- pregnancy test
- amylase and lipase
- cardiac enzymes
- creatinine kinase
- chest x-ray
- liver function tests
- blood, urine, and sputum cultures
initial systolic blood pressure <90 mmHg
initial systolic blood pressure ≥90 mmHg
Gerry Rayman, MD, FRCP
Consultant Physician and Head of Service
Diabetes and Endocrine Centre and the Diabetes Research Unit
Ipswich Hospitals NHS Trust
GR is Lead and Innovator of the National Inpatient Diabetes Audit; and Joint Clinical Lead of the Diabetes, Getting It Right First Time programme.
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.
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
Laleh Razavi Nematollahi, MD
Assistant Professor of Medicine
Case Western Reserve University
ARG and LRN declare that they have no competing interests.
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
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
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.
Section Editor, BMJ Best Practice
AS declares that she has no competing interests.
Head of Research and Development, BMJ
LD declares that she has no competing interests.
Head of Editorial, BMJ Best Practice
AE declares that she has no competing interests.
Lead Section Editor, BMJ Best Practice
RW declares that she has no competing interests.
Comorbidities Editor, BMJ Best Practice
JC declares that she has no competing interests.
Drug Editor, BMJ Best Practice
AM declares that he has no competing interests.
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