Diabetic ketoacidosis

Date Updated: 11/11/2020

Overview

Diabetic ketoacidosis is a serious complication of diabetes that occurs when your body produces high levels of blood acids called ketones.

The condition develops when your body can't produce enough insulin. Insulin normally plays a key role in helping sugar (glucose) — a major source of energy for your muscles and other tissues — enter your cells. Without enough insulin, your body begins to break down fat as fuel. This process produces a buildup of acids in the bloodstream called ketones, eventually leading to diabetic ketoacidosis if untreated.

If you have diabetes or you're at risk of diabetes, learn the warning signs of diabetic ketoacidosis and when to seek emergency care.

Symptoms

Diabetic ketoacidosis signs and symptoms often develop quickly, sometimes within 24 hours. For some, these signs and symptoms may be the first indication of having diabetes. You may notice:

Excessive thirst
Frequent urination
Nausea and vomiting
Stomach pain
Weakness or fatigue
Shortness of breath
Fruity-scented breath
Confusion

More-specific signs of diabetic ketoacidosis — which can be detected through home blood and urine testing kits — include:

High blood sugar level
High ketone levels in your urine

When to see a doctor

If you feel ill or stressed or you've had a recent illness or injury, check your blood sugar level often. You might also try an over-the-counter urine ketones testing kit.

Contact your doctor immediately if:

You're vomiting and unable to tolerate food or liquid
Your blood sugar level is higher than your target range and doesn't respond to home treatment
Your urine ketone level is moderate or high

Seek emergency care if:

Your blood sugar level is consistently higher than 300 milligrams per deciliter (mg/dL), or 16.7 millimoles per liter (mmol/L)
You have ketones in your urine and can't reach your doctor for advice
You have many signs and symptoms of diabetic ketoacidosis — excessive thirst, frequent urination, nausea and vomiting, stomach pain, weakness or fatigue, shortness of breath, fruity-scented breath, and confusion

Remember, untreated diabetic ketoacidosis can lead to death.

Causes

Sugar is a main source of energy for the cells that make up your muscles and other tissues. Normally, insulin helps sugar enter your cells.

Without enough insulin, your body can't use sugar properly for energy. This prompts the release of hormones that break down fat as fuel, which produces acids known as ketones. Excess ketones build up in the blood and eventually "spill over" into the urine.

Diabetic ketoacidosis is usually triggered by:

An illness. An infection or other illness can cause your body to produce higher levels of certain hormones, such as adrenaline or cortisol. Unfortunately, these hormones counter the effect of insulin — sometimes triggering an episode of diabetic ketoacidosis. Pneumonia and urinary tract infections are common culprits.
A problem with insulin therapy. Missed insulin treatments or inadequate insulin therapy or a malfunctioning insulin pump can leave you with too little insulin in your system, triggering diabetic ketoacidosis.

Other possible triggers of diabetic ketoacidosis include:

Physical or emotional trauma
Heart attack or stroke
Pancreatitis
Pregnancy
Alcohol or drug abuse, particularly cocaine
Certain medications, such as corticosteroids and some diuretics

Risk factors

The risk of diabetic ketoacidosis is highest if you:

Have type 1 diabetes
Frequently miss insulin doses

Uncommonly, diabetic ketoacidosis can occur if you have type 2 diabetes. In some cases, diabetic ketoacidosis may be the first sign that you have diabetes.

Complications

Diabetic ketoacidosis is treated with fluids, electrolytes — such as sodium, potassium and chloride — and insulin. Perhaps surprisingly, the most common complications of diabetic ketoacidosis are related to this lifesaving treatment.

Possible complications of the treatments

Treatment complications include:

Low blood sugar (hypoglycemia). Insulin allows sugar to enter your cells, causing your blood sugar level to drop. If your blood sugar level drops too quickly, you can develop low blood sugar.
Low potassium (hypokalemia). The fluids and insulin used to treat diabetic ketoacidosis can cause your potassium level to drop too low. A low potassium level can impair the activities of your heart, muscles and nerves. To avoid this, electrolytes, including potassium are usually given along with fluid replacement as part of the treatment of diabetic ketoacidosis.
Swelling in the brain (cerebral edema). Adjusting your blood sugar level too quickly can produce swelling in your brain. This complication appears to be more common in children, especially those with newly diagnosed diabetes.

Left untreated, the risks of diabetic ketoacidosis are much greater. Diabetic ketoacidosis can lead to loss of consciousness and, eventually, death.

Prevention

There's much you can do to prevent diabetic ketoacidosis and other diabetes complications.

Commit to managing your diabetes. Make healthy eating and physical activity part of your daily routine. Take oral diabetes medications or insulin as directed.
Monitor your blood sugar level. You might need to check and record your blood sugar level at least three to four times a day, or more often if you're ill or stressed. Careful monitoring is the only way to make sure that your blood sugar level stays within your target range.
Adjust your insulin dosage as needed. Talk to your doctor or diabetes educator about how to adjust your insulin dosage in relation to factors such as your blood sugar level, what you eat, how active you are, and whether you're ill. If your blood sugar level begins to rise, follow your diabetes treatment plan to return your blood sugar level to your target range.
Check your ketone level. When you're ill or stressed, test your urine for excess ketones with an over-the-counter urine ketones test kit. If your ketone level is moderate or high, contact your doctor right away or seek emergency care. If you have low levels of ketones, you may need to take more insulin.
Be prepared to act quickly. If your blood sugar is high and you have excess ketones in your urine, and you think that you have diabetic ketoacidosis, seek emergency care.

Diabetes complications are scary. But don't let fear keep you from taking good care of yourself. Follow your diabetes treatment plan carefully. Ask your diabetes treatment team for help when you need it.

Diagnosis

If your doctor suspects diabetic ketoacidosis, he or she will do a physical exam and order blood tests. In some cases, additional tests may be needed to help determine what triggered the diabetic ketoacidosis.

Blood tests

Blood tests used in the diagnosis of diabetic ketoacidosis will measure:

Blood sugar level. If there isn't enough insulin in your body to allow sugar to enter your cells, your blood sugar level will rise (hyperglycemia). As your body breaks down fat and protein for energy, your blood sugar level will continue to rise.
Ketone level. When your body breaks down fat and protein for energy, acids known as ketones enter your bloodstream.
Blood acidity. If you have excess ketones in your blood, your blood will become acidic (acidosis). This can alter the normal function of organs throughout your body.

Additional tests

Your doctor may order tests to identify underlying health problems that might have contributed to diabetic ketoacidosis and to check for complications. Tests might include:

Blood electrolyte tests
Urinalysis
Chest X-ray
A recording of the electrical activity of the heart (electrocardiogram)

Treatment

If you're diagnosed with diabetic ketoacidosis, you might be treated in the emergency room or admitted to the hospital. Treatment usually involves:

Fluid replacement. You'll receive fluids — either by mouth or through a vein — until you're rehydrated. The fluids will replace those you've lost through excessive urination, as well as help dilute the excess sugar in your blood.
Electrolyte replacement. Electrolytes are minerals in your blood that carry an electric charge, such as sodium, potassium and chloride. The absence of insulin can lower the level of several electrolytes in your blood. You'll receive electrolytes through a vein to help keep your heart, muscles and nerve cells functioning normally.
Insulin therapy. Insulin reverses the processes that cause diabetic ketoacidosis. In addition to fluids and electrolytes, you'll receive insulin therapy — usually through a vein. When your blood sugar level falls to about 200 mg/dL (11.1 mmol/L) and your blood is no longer acidic, you may be able to stop intravenous insulin therapy and resume your normal subcutaneous insulin therapy.

As your body chemistry returns to normal, your doctor will consider additional testing to check for possible triggers for the diabetic ketoacidosis. Depending on circumstances, you might need additional treatment.

For example, your doctor will help you create a diabetes treatment plan. If a bacterial infection is found, he or she might prescribe antibiotics. If a heart attack seems possible, your doctor might recommend further evaluation of your heart.

Preparing for an appointment

Diabetic ketoacidosis is life-threatening. If you develop mild signs and symptoms, contact your doctor immediately.

Call 911 or your local emergency number if:

You can't reach your doctor
Your symptoms are getting worse
Your symptoms are already severe

A medical provider who sees you for possible diabetic ketoacidosis will need answers to these questions as quickly as possible:

What are your signs and symptoms?
When did these signs and symptoms develop? Are they getting worse?
Have you been diagnosed with diabetes?
Have you recently checked your blood sugar level?
Have you recently checked your ketone level?
Have you lost your appetite?
Can you keep fluids down?
Are you having trouble breathing?
Do you have chest pain?
Have you had a recent illness or infection?
Have you had recent stress or trauma?
Have you recently used alcohol or recreational drugs?
How closely have you been following your diabetes treatment plan?
How well would you say your diabetes has been managed just before these symptoms?