Diabetic Ketoacidosis



  • Severe metabolic derangement in patients with diabetes mellitus secondary to insulin deficiency and/or stress hormone excess
  • Clinical features include hyperglycemia, ketosis, metabolic acidosis, dehydration, and electrolyte deficits.


  • Diabetes ketoacidosis (DKA) occurs more commonly in type 1 diabetes (T1D) but can also occur in type 2 diabetes (T2D).
  • 20–40% of children with new-onset T1D present in DKA
  • Risk of DKA in established T1D is 1–10% per patient per year (most episodes caused by insulin omission/diabetes mismanagement).
  • DKA accounts for majority of diabetes-related deaths in childhood (most secondary to cerebral edema/brain injury).

Risk Factors

  • For T1D presenting as DKA:
    • Very young children (<5 years)
    • Ethnic minority
    • Inadequate health insurance
    • A missed diagnosis of diabetes in preceding clinic visits is frequent in DKA patients (~35%).
  • For DKA in established diabetes:
    • Adolescence
    • Lack of health insurance
    • Poor glycemic control
    • Ethnic minority
    • Low socioeconomic status (SES)

General Prevention

  • Prompt diagnosis of new-onset diabetes (e.g., urinalysis in patients with poor weight gain, polyuria, influenza-like symptoms, vomiting)
  • Patient/parental education regarding ketone testing (with any symptoms of illness or unexplained high blood glucose level)
  • Strict supervision of long-acting (glargine, detemir) insulin injections by parents
  • Detection and avoidance of insulin pump interruptions by frequent blood glucose testing and strict protocols for changing infusion sets


  • Excess of counterregulatory “stress” hormone concentrations (glucagon, cortisol, and epinephrine) in relation to insulin concentrations occurs, either as a result of insulin absence (new-onset diabetes or insulin omission) or illness (raising stress hormone levels).
  • Imbalance between counterregulatory hormones and insulin results in increased glycogenolysis and gluconeogenesis and decreased peripheral glucose uptake (causing hyperglycemia) as well as lipolysis and ketogenesis (causing ketosis).
  • Hyperglycemia causes osmotic diuresis resulting in dehydration and electrolyte losses.
  • Ketogenesis results in metabolic acidosis, causing vomiting and tachypnea.
  • Dehydration causes poor tissue perfusion, raising lactate levels and is contributing to metabolic acidosis.


  • Insulin deficiency
    • New diagnosis of diabetes
    • Insulin omission (diabetes mismanagement or insulin pump malfunction)
  • Acute illness (leading to rise in counterregulatory hormone levels)

Commonly Associated Conditions

  • Acute illness as a precipitating factor
  • Autoimmune disorders (especially hypothyroidism) for persons with T1D

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