Diabetic Ketoacidosis

Overview

Diabetic ketoacidosis — usually called DKA — is a serious and sudden complication of diabetes. It happens when your body does not have enough insulin (the hormone that moves sugar from your blood into your cells for energy). Without insulin, your cells cannot use sugar, so your body starts burning fat for fuel instead. Burning fat quickly makes substances called ketones (a type of acid). When ketones build up in your blood, your blood becomes too acidic, and this can become a life-threatening emergency. DKA is most common in people with type 1 diabetes, but it can also happen in people with type 2 diabetes, especially during illness or severe stress. DKA is treatable, and most people recover fully with prompt hospital care. The key is to recognise the warning signs early and get help fast.

DKA is not rare. It is one of the most common serious diabetes emergencies, and it is the reason many people with type 1 diabetes are first diagnosed. Rates vary between countries, but doctors see it regularly in emergency departments everywhere. In people already diagnosed with diabetes, DKA can often be prevented with good day-to-day diabetes care and a clear plan for sick days.

DKA can affect anyone with diabetes, at any age. It is most common in people with type 1 diabetes, and in children and young adults when diabetes is first found. It can also happen in people with type 2 diabetes, particularly older adults, people who are unwell or dehydrated, and people who use certain diabetes medicines. It is more likely during infections, after missed insulin, during pregnancy, and in people who are having difficulty affording or accessing their insulin. It is not caused by anything you did wrong, and it is not a sign of weakness.

Symptoms

Common symptoms

• Feeling very thirsty and needing to pass urine much more than usual, especially at night
• Feeling very tired, weak, or drained
• Feeling sick (nausea) or being sick (vomiting)
• Tummy pain, sometimes severe
• Breath that smells fruity, like pear drops or nail polish remover
• Fast, deep breathing, or feeling short of breath
• Dry mouth, dry skin, and feeling very thirsty with no quench
• Blurred vision
• Feeling confused, drowsy, or not quite yourself
• High blood sugar readings, often with high ketone readings if you test for them

Symptoms in children

• Being unusually sleepy, floppy, or hard to wake
• Fast or heavy breathing, sometimes mistaken for a chest infection
• Tummy pain and vomiting, which can be mistaken for a tummy bug
• Needing to drink and pass urine far more than usual, sometimes with new bedwetting
• Weight loss over a few weeks, with a big appetite at first
• Fruity-smelling breath, or a smell some parents describe as like nail varnish
• In babies and toddlers: nappies that are much heavier, and unusual drowsiness — seek help the same day

Symptoms in older adults

• Confusion, unusual sleepiness, or a sudden change in behaviour that can be mistaken for a stroke or infection
• Very high blood sugar with few of the classic thirst symptoms, especially if you do not feel thirsty as much as you used to
• Dehydration and low blood pressure, leading to dizziness on standing or falls
• DKA can happen in type 2 diabetes in older adults, sometimes without very high sugar levels
• Vomiting and not keeping fluids down, which is riskier when you are frail
• If you take medicines called SGLT2 inhibitors (a type of diabetes tablet), DKA can rarely occur even with normal or only slightly high sugar levels — ask your diabetes team about this

Causes

Main causes

• Not having enough insulin — missed doses, running out, a blocked or dislodged pump, or insulin that has been damaged by heat or freezing
• Illness or infection (such as flu, chest infection, urine infection, or a tummy bug) — the body releases stress hormones that raise blood sugar
• Newly developing type 1 diabetes that has not yet been diagnosed
• Injury, surgery, or a heart attack or stroke, which put the body under major stress
• Certain diabetes medicines, rarely, including a group of tablets called SGLT2 inhibitors (ask your diabetes team if you take one)
• Alcohol or drug use, especially binge drinking, which can cause vomiting and missed insulin
• Pregnancy, particularly in people with pre-existing diabetes, and sometimes as a first sign of diabetes in pregnancy

Risk factors

• Having type 1 diabetes, especially if you are young
• Having had DKA before — it can happen again
• Being unwell with an infection, or having another serious illness
• Not being able to afford insulin, or difficulty getting to a pharmacy or doctor
• Problems with an insulin pump, or with injecting and counting insulin correctly
• Being a teenager or young adult — hormones, routine changes and stress can make diabetes harder to manage
• Having an eating disorder, or deliberately skipping insulin to lose weight (this is dangerous and help is available)
• Being frail, or living with dementia, where it can be easy to miss doses or early signs of illness
• Very hot weather or dehydration

When to see a doctor

See a doctor urgently if:

• Call your local emergency number if you or someone else is very drowsy, confused, breathing fast or deeply, has severe tummy pain, or cannot keep fluids down
• Contact your diabetes team or an urgent care service the same day if your blood sugar stays high and you have moderate or high ketones
• Contact your doctor the same day if you are vomiting and cannot keep fluids down, or if an illness is making your diabetes very hard to control
• Get help the same day if you have symptoms of DKA but have not been diagnosed with diabetes
• Seek same-day advice if your insulin supply is low, your pen or pump is not working, or your insulin may have got too hot or too cold

Book a routine appointment if:

• Book a review with your diabetes team if you have had DKA, to talk about what caused it and how to prevent it
• Ask for a check-up if you often have high blood sugar readings, or if your sugar is hard to control
• Talk to your team if you are struggling with the cost of insulin, testing strips, or equipment
• Ask for a review if you feel your sick-day plan is out of date, or you are not sure what to do when you are ill
• Speak to your doctor if you feel low in mood, or if you have been tempted to skip insulin

Diagnosis

DKA is diagnosed quickly, usually in an emergency department or urgent care setting. A doctor will ask about your symptoms, check your breathing and alertness, and take blood and urine tests. The tests look for high blood sugar, a build-up of acids called ketones, and changes in the salts and fluid levels in your body. Together, these results confirm whether you have DKA and how serious it is. In someone not yet diagnosed with diabetes, these tests can also reveal diabetes for the first time.

Tests that may be done

• A finger-prick blood sugar test — a quick reading taken in seconds
• A blood ketone test, or a urine ketone test, to measure the acids your body is making
• A blood test to check the acid level in your blood (called a blood gas test)
• Blood tests for salts and minerals such as potassium and sodium, which can become unbalanced in DKA
• Kidney function tests
• A test to check for infection, such as a urine test, chest X-ray, or blood cultures, if an infection may have triggered it
• An ECG (heart tracing) if your potassium is low, because this can affect the heart rhythm
• In some cases, a test called HbA1c, which shows your average blood sugar over the past few weeks

What to expect at your appointment

If DKA is suspected, you will usually be seen straight away. You will be given a bed, have a thin tube (a cannula) placed in a vein in your arm, and be given fluids through a drip. You will be monitored closely — blood sugar and ketones checked every hour or so at first. You may feel very tired and thirsty, and you may need to stay in hospital for a day or two, sometimes longer. Most people start to feel much better within hours of treatment starting. Bring a phone and charger if you can, and let staff know about any other conditions or medicines.

Treatment

DKA is treated in hospital, usually in an emergency department and then on a ward or a high-dependency unit. Treatment has three main parts: replacing the fluid you have lost through a drip, giving insulin to switch your body back to using sugar, and replacing salts and minerals such as potassium that get out of balance. Staff will check your blood sugar, ketones and blood chemistry regularly and adjust treatment as you improve. Most people feel better quickly. Once you are stable, can eat and drink, and your ketones have cleared, you can usually go home with a plan to prevent it happening again.

Self-care at home

• Follow your diabetes team's sick-day plan whenever you are ill — this usually means checking blood sugar and ketones more often and never stopping insulin unless you are told to
• Keep testing strips, ketone strips, spare insulin, and spare pen needles or pump supplies at home
• Drink plenty of sugar-free fluids when you are ill, and sip small amounts often if you feel sick
• Store insulin correctly — never use insulin that has been frozen or left in a hot car or sunny window
• Wear or carry medical ID saying you have diabetes
• Know your own early warning signs and act on them early rather than waiting
• After you get home, take it gently for a few days and keep in touch with your diabetes team
• Ask your team to review your sick-day plan at least once a year

Medical treatments

In hospital, treatment is given through a drip into a vein. This usually includes fluids to rehydrate you, insulin to bring your blood sugar down steadily, and replacement of salts and minerals such as potassium. Staff monitor you closely with repeat blood tests until your ketones have cleared and your blood chemistry is back to normal. Any trigger — such as an infection — is also looked for and treated. You will not be sent home until you are stable, eating and drinking, and your ketone levels are safe. Your diabetes team will then help you adjust your usual insulin plan so it works better for you. Specific medicines and doses are always decided by your treating doctors.

When is surgery considered?

Surgery is not a treatment for DKA. However, if DKA is triggered by a condition that needs an operation — such as a severe infection or, rarely, a serious abdominal problem — the surgical team and diabetes team will work together. They will stabilise your diabetes and blood chemistry first, and plan any operation carefully around your insulin needs. Always tell any surgeon and anaesthetist that you have diabetes and have had DKA.

Living with this condition

Living well with diabetes is about routines, not perfection. Checking your blood sugar regularly, taking insulin as planned, and knowing what to do on a bad day makes a big difference. Have a sick-day plan written down where you can find it quickly. Keep a small emergency kit with you — testing strips, ketone strips, a snack, and a phone number for your diabetes team. Tell the people you live or work with what to look out for, and what to do if you become unwell. After a DKA episode, it is worth going through what happened with your team so you can spot the pattern and prevent a repeat.

Lifestyle tips

• Plan ahead for illness, travel, exams, festivals and other times when routine gets disrupted
• Avoid binge drinking, and never skip insulin because of alcohol or to control weight
• Check your feet and general health regularly, as diabetes affects healing and infection risk
• Keep spare insulin in a cool, safe place, and check expiry dates
• Carry medical ID and a phone with emergency contacts
• Ask for help early if money, housing or mental health is making diabetes hard to manage

Diet and exercise

There is no single 'diabetes diet'. A balanced way of eating with regular meals, plenty of vegetables, and limited sugary drinks helps keep blood sugar steadier. If you take insulin, learn how your meals and portions affect your readings, and ask your team about counting carbohydrates if you have not already. Exercise is good for you and helps your body use insulin better — but it can also lower blood sugar, so check your readings before, during and after activity, and keep a fast-acting sugary snack with you in case of a low. When you are unwell, food may not appeal, but you still need fluids and insulin. Your team can help you build an eating and activity plan that fits your life.

Mental health and emotional wellbeing

A DKA episode can leave you feeling shaken, guilty, or anxious about it happening again. That is really common. Managing diabetes every day is demanding, and 'diabetes distress' or burnout is a real thing — feeling worn down by the constant checking and planning. Some people skip insulin when they feel low or worried about weight, which raises DKA risk; this is a sign to reach out, not a failure. Talking to your diabetes team, a counsellor, or a peer support group can help a lot. If you ever feel you cannot keep going, or have thoughts of harming yourself, contact your local emergency number or a crisis line straight away — you deserve support and you are not alone.

Prevention

Often, yes. DKA is one of the diabetes emergencies that can usually be prevented with planning. The most important steps are never stopping insulin without medical advice, following a sick-day plan when you are ill, checking blood sugar and ketones more often when you feel unwell, and getting help early if readings stay high. Make sure you always have enough insulin and testing supplies. Teach the people around you the warning signs. If you have had DKA before, ask your team for a prevention review — this really does reduce the chance of it happening again.

Vaccines

There is no vaccine for DKA. However, recommended vaccines — such as flu and pneumonia vaccines — help prevent the infections that often trigger DKA. Ask your doctor or pharmacist which vaccinations are advised for you, as recommendations vary by country and by age.

Screening programmes

There is no screening test for DKA itself. What does help is regular diabetes review, including checks on your average blood sugar, kidney function, blood pressure, feet and eyes. These reviews are a chance to spot problems early and update your care plan. If you have symptoms of diabetes and have not been diagnosed — such as being very thirsty, passing lots of urine, and losing weight — ask for a blood sugar test promptly.

Complications

If left untreated

• Severe dehydration, which can affect how well your heart and kidneys work
• Dangerously low levels of salts such as potassium, which can disturb the heart rhythm
• Swelling of the brain (cerebral oedema) — rare but serious, and more likely in children
• Fluid in the lungs, or blood clots
• Coma and, in the most serious cases, death — which is why fast treatment matters so much
• After recovery, some people feel exhausted for a few days and need time to get back to normal

Long-term outlook

The outlook is good. With timely treatment, most people with DKA recover fully and go home within a day or two, with no lasting harm. DKA is serious, but it is also very treatable and largely preventable. Many people who have had it go on to manage their diabetes well for years. If you have had an episode, use it as a chance to review your plan with your team — that is how people turn a scary experience into stronger, safer day-to-day care.

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