Diabetic ketoacidosis (DKA) is a life-threatening acute metabolic complication of diabetes mellitus caused by severe insulin deficiency leading to hyperglycaemia, ketone production and metabolic acidosis. It may present with dehydration and reduced level of consciousness and requires urgent hospital management.

Pathophysiology: Insulin deficiency → ↑ lipolysis → ketone body production → metabolic acidosis + osmotic diuresis → dehydration + electrolyte loss.

Risk Factors

• Newly diagnosed diabetes (especially type 1 DM)

• Poor adherence to insulin therapy

• Infection (UTI, pneumonia, sepsis)

• Myocardial infarction

• Stroke

• Trauma or surgery

• Pregnancy

• Pancreatitis

• Drugs: steroids, thiazides, antipsychotics

• Substance abuse

• Insulin pump failure

Signs and Symptoms

• Nausea and vomiting

• Abdominal pain

• Shortness of breath

• Kussmaul breathing (deep laboured breathing)

• Fruity smelling breath (acetone)

• Thirst and polyuria

• Dehydration

• Fever (often infection trigger)

• Lethargy

• Confusion

• Drowsiness/obtundation

• Altered mental function

• Coma (late sign)

Diagnostic Criteria

Diagnosis is made when the following are present:

• Blood glucose > 11 mmol/L or known diabetes mellitus

• Ketonuria ++ or more (or ketonaemia)

• Metabolic acidosis

Severity indicators:

• Glasgow Coma Scale <12

• Systolic BP <90 mmHg

• Pulse >100 bpm or <60 bpm

Investigations

• Capillary blood glucose

• Urine or blood ketones

• Arterial or venous blood gases (acidosis)

• Serum electrolytes (Na⁺, K⁺, Cl⁻)

• Urea and creatinine

• Full blood count

• Infection screening (urine, blood cultures, CXR)

Management

Medical emergency — admit urgently (high dependency or ICU).

Treatment priorities

1. Fluid resuscitation

2. Potassium correction

3. Insulin therapy

4. Treat precipitating cause

Non-Pharmacological

• Admit for intensive monitoring

• Use DKA treatment chart

• Insert nasogastric tube if reduced consciousness

• Strict input/output monitoring

• Urinary catheter if no urine after 2 hours

• Screen and treat infection

• Monitor cardiovascular status for fluid overload

Pharmacological

1. Fluid and Electrolyte Replacement

If systolic BP <90 mmHg

• 0.9% Sodium chloride 500 mL over 10–15 minutesRepeat once if still hypotensive

• If still low → look for septic shock or cardiac failure

• Do NOT use plasma expanders

If systolic BP ≥90 mmHg

• Normal saline 1 L + KCl 2 g every 2 hours for first 4 hours, then every 4 hoursOR

• Ringer’s lactate 1 L every 2 hours for first 4 hours, then every 4 hours

When glucose ≤14 mmol/L:

• Start 5% dextrose 500 mL every 4 hours

• Continue saline if dehydration persists

Use cautious fluids in:

• Young adults (18–25)

• Elderly

• Pregnancy

• Cardiac or renal failure

2. Insulin Therapy

Initial:

• Soluble insulin 8 IU (0.1 IU/kg) IV AND 8 IU IM stat

Maintenance:

• 8 IU IM hourly

Glucose monitoring:

• Every 2 hours (IM route) or 4 hourly (SC)

Target:

• Fall in glucose ≈ 3 mmol/L per hour

If glucose fluctuates widely → adjust hourly insulin increments by 1 IU/hour

When glucose ≤14 mmol/L:

• Insulin 4 IU SC 4 hourly OR IM 2 hourly

• Continue until patient eats

Then convert to maintenance insulin:

Total daily dose: 0.5–0.75 IU/kg/day

Option 1:

• 50% long-acting evening

• Remaining divided before meals

Option 2:

• Premixed insulin: 2/3 morning, 1/3 evening

3. Potassium Management

• Total body potassium is depleted even if lab value normal/high.

• Replace potassium unless severe hyperkalaemia present.

4. Sodium Bicarbonate

• Only in severe acidosis (doctor’s decision)

• NaHCO₃ 50 mmol

5. Additional Measures

• Maintain urine output ≥0.5 mL/kg/hour

• Monitor for pulmonary oedema

• Antibiotics if infection suspected

Prevention

• Patient education on insulin adherence

• Sick-day rules (never stop insulin)

• Early infection treatment

• Home glucose and ketone monitoring

• Regular clinic follow-up

• Proper insulin storage