Introduction to diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is a medical emergency requiring specialist care, and should generally be managed in hospital. Children and adolescents with suspected DKA require urgent hospital admission. Do not use an adult DKA protocol to guide management of children and adolescents.

DKA is characterised by dehydration, hyperglycaemia, polyuria, polydipsia and tachypnoea. Additional clinical signs include deep sighing respiration, breath smelling of acetone, nausea and/or vomiting, abdominal pain, confusion, drowsiness and progressive decrease in level of consciousness. Stresses such as infection, inappropriate withdrawal of insulin (eg disruption of insulin delivery from a subcutaneous insulin pump [eg kink in or blockage of cannula]), myocardial infarction or trauma are the most common precipitants of DKA. In young adults and adolescents, omitting insulin doses is a common cause.

DKA occurs mainly in patients with type 1 diabetes. However, it is also seen in patients with type 2 diabetes, particularly patients taking sodium-glucose co-transporter 2 (SGLT2) inhibitors, when DKA may occur without hyperglycaemia.

There are no definitive criteria for the diagnosis of DKA. Typically, the arterial pH is 7.3 or less, serum bicarbonate is 15 mmol/L or less, and the anion gap is more than 12 mmol/L with elevated blood ketone concentration or positive urine ketone result. Blood glucose concentration is usually 14 mmol/L or more but can be lower, especially if the patient is taking an SGLT2 inhibitor.