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Diabetic ketoacidosis Content Supplied by NHS Choices
Introduction

Diabetic ketoacidosis is a potentially life-threatening complication of diabetes caused by a lack of insulin in the body.

It occurs when the body is unable to use blood sugar (glucose) because there isn't enough insulin. Instead, it breaks down fat as an alternative source of fuel. This causes a build-up of a potentially harmful by-product called ketones.

Read more about the causes of diabetic ketoacidosis.

It's fairly common in people with type 1 diabetes and can very occasionally affect those with type 2 diabetes. It sometimes develops in people who were previously unaware they had diabetes. Children and young adults are most at risk.

It's important to seek medical advice quickly if you think that you or your child is experiencing the condition, because serious complications of diabetic ketoacidosis can develop if it's not treated early on.

Warning signs to look out for

If you take insulin to control your diabetes, you should keep an eye out for signs and symptoms of diabetic ketoacidosis.

Early signs and symptoms can include:

You may become very dehydrated and if the condition isn't treated quickly, it can lead to vomiting, an increased breathing and heart rate, dizziness, drowsiness, a smell of pear drops or nail varnish on your breath, and loss of consciousness.

Read more about the symptoms of diabetic ketoacidosis.

What to do

If you think that you or your child are experiencing early symptoms of diabetic ketoacidosis, and self-testing shows you have a high blood glucose and/or ketone level, you should immediately contact your diabetes care team or GP for advice.

If this isn't possible, call your local out-of-hours service or NHS 111.

If you or someone in your care appears to be experiencing more advanced symptoms, go immediately to your nearest accident and emergency (A&E) department.

Treatment in hospital

In most cases, people with diabetic ketoacidosis need to be treated in hospital.

While in hospital, you'll usually receive a combination of:

  • fluids pumped directly into a vein to rehydrate your body
  • insulin (usually pumped into a vein)
  • replacement of minerals you may have lost, such as potassium

You'll be closely monitored to check how well you're responding to treatment.

As long as there are no further problems, you should be able to leave hospital when you're well enough to eat and drink normally and tests show a safe level of ketones in your body.

Before being discharged from hospital, a diabetes nurse will talk to you about why you developed diabetic ketoacidosis and help you come up with a plan to prevent future episodes.

Read more about treating diabetic ketoacidosis.

Be aware of the danger

If you have type 1 diabetes, you're at risk of diabetic ketoacidosis when your insulin level drops and your blood sugar level starts to rise (hyperglycaemia).

This often occurs when you're ill with an infection such as flu or a urinary tract infection (UTI), as this causes the body to release extra hormones into your blood to help combat the illness. These hormones interfere with the effect of insulin, meaning that you need more insulin. It can also occur if you don't have enough insulin because you aren't following your recommended treatment plan correctly.

A simple finger prick blood test can be used to detect an increase in blood sugar before it becomes a serious problem. Kits can also check the level of ketones in urine. You should monitor your blood sugar and ketone levels closely if you have type 1 diabetes, particularly when you're ill, so you can spot any increases early on.

Generally speaking, a blood sugar reading of 11 mmol/l or more is a sign that you're at risk of diabetic ketoacidosis and should check your ketone level if you feel ill. A ketone level reading of 2+ or more on urine strips or 0.6 mmol/l or more in your blood is a sign that you need to take immediate action to correct your levels.

Adjusting your insulin dose as advised by your diabetes care team will often correct your blood sugar and ketone levels, preventing diabetic ketoacidosis. Seek medical advice if your levels remain high after taking insulin or you develop the symptoms mentioned above.

Read more about the causes of diabetic ketoacidosis and preventing diabetic ketoacidosis.

Symptoms of diabetic ketoacidosis

The initial symptoms of diabetic ketoacidosis can develop quite suddenly and will continue to get worse if not treated.

Early symptoms

In the early stages, the main signs of diabetic ketoacidosis are:

You may also develop other symptoms of dehydration, such as a dry mouth.

If you have your own device or kit to measure your blood sugar and/or ketone levels, you may notice that the levels of both of these are higher than normal.

Advanced symptoms

Left untreated, more advanced symptoms can develop, such as:

  • rapid heartbeat (tachycardia)
  • rapid breathing, where you breathe in more oxygen than your body actually needs (hyperventilate)
  • vomiting
  • dizziness
  • a smell of ketones on your breath, which can smell like pear drops or nail varnish remover
  • confusion
  • drowsiness or loss of consciousness (coma)

In some cases, life-threatening complications of diabetic ketoacidosis can also develop.

When to seek medical advice

If you think you or your child are experiencing early symptoms of diabetic ketoacidosis, and self-testing shows you have a high blood glucose and/or ketone level, you should immediately contact your diabetes care team or GP for advice.

If this isn't possible, call your local out-of-hours service or NHS 111.

If you or someone in your care appears to be experiencing more advanced symptoms, go immediately to your nearest accident and emergency (A&E) department.

Causes of diabetic ketoacidosis

Diabetic ketoacidosis is a complication of diabetes that can occur if the body starts to run out of insulin.

Insulin enables the body to use blood sugar (glucose). If there is a lack of insulin, or if it can't be used properly, the body will break down fat instead.

The breakdown of fat releases harmful, acidic substances called ketones, and the lack of insulin in your body leads to high blood glucose levels (hyperglycaemia).

The combination of high ketone and blood sugar levels can cause a number of symptoms that can be very serious if the levels aren't corrected quickly. Read more about the symptoms of diabetic ketoacidosis.

High levels of ketones and blood sugar can be detected in your blood or urine using self-testing devices or kits. It's important to monitor your levels regularly if you have type 1 diabetes, so you can spot any potential problems early on.

Read more about preventing diabetic ketoacidosis.

Diabetic ketoacidosis triggers

Common triggers for the reduction in insulin levels leading to diabetic ketoacidosis include:

  • an underlying infection - such as a urinary tract infection (UTI), gastroenteritis, flu or pneumonia
  • missed insulin treatment - this may be because you find it difficult to use your insulin injectors, there's a problem with your injector or pump, your treatment regimen has recently changed, or you're intentionally not treating yourself
  • previously undiagnosed diabetes (usually type 1 diabetes)

Less common triggers include taking certain medications (such as corticosteroids), using illegal drugs, binge drinking, and having a stroke or heart attack.

Treating diabetic ketoacidosis

Diabetic ketoacidosis is usually treated in hospital.

Depending on how advanced your symptoms are, you may be admitted to a standard ward, a high dependency ward or an intensive care unit (ICU).

Diabetic ketoacidosis is treated using a combination of:

  • fluids pumped directly into a vein to rehydrate your body
  • insulin (usually pumped into a vein)
  • replacement of minerals, such as potassium, which may have been lost because you're dehydrated and because of insulin treatment

You'll be closely monitored using blood and urine tests to check how well you're responding to treatment and determine when it's safe for you to go home.

If you develop any complications of diabetic ketoacidosis, you'll need additional treatment for this.

Going home

As long as there are no complications, you should be able to leave hospital when you are well enough to eat and drink normally and tests show no, or few, ketones left in your body.

In most cases, this will take less than 24 hours, although some people may need to stay in hospital for longer.

Before or shortly after being discharged from hospital, your diabetes nurse will discuss why you developed diabetic ketoacidosis, so a plan can be put in place to prevent future episodes.

For example, if diabetic ketoacidosis was caused by an illness, you'll need a "sick day plan" so you can adjust your insulin dosage accordingly.

If diabetic ketoacidosis occurred as a result of missing an insulin treatment, you'll need to discuss the reasons for this and whether there's anything that can be done to make your treatment plan easier to follow.

Read more about preventing diabetic ketoacidosis.

Complications of diabetic ketoacidosis

With prompt treatment, diabetic ketoacidosis can be corrected without any complications developing. If left untreated, the condition can be life-threatening.

Certain groups of people are more likely to develop serious problems from diabetic ketoacidosis. These include young children, elderly people, and those with another serious underlying condition.

Some of the main complications of diabetic ketoacidosis are described below.

Hypokalaemia

If you're urinating a lot and vomiting because of diabetic ketoacidosis, you're likely to become dehydrated and lose important minerals, such as potassium.

If your potassium levels fall to a dangerously low level, it's known as hypokalaemia. This is one of the main causes of deaths in adults with diabetic ketoacidosis.

Hypokalaemia can cause a number of problems, some of which can be very serious. These include:

  • weakness and fatigue
  • muscle cramps
  • constipation
  • breathing difficulties
  • an abnormal heart rhythm (arrhythmia)

Hypokalaemia occurring with diabetic ketoacidosis usually needs to be treated by giving extra potassium in hospital via a drip into a vein.

A reduction in potassium levels can also occur after insulin treatment in hospital, but you will be closely monitored for this and given extra potassium if necessary.

Acute kidney failure

Severe dehydration can cause your kidneys to stop working (acute kidney failure).

Your kidneys remove waste products from your blood, so if they stop working you may experience a range of symptoms, such as:

  • swelling in your arms and legs caused by a build-up of fluid (oedema)
  • feeling sick
  • feeling very tired
  • confusion

Until your dehydration has been successfully treated, you may need dialysis, where a machine filters waste products from your blood.

Once your fluid levels have been restored to normal, your kidneys should start to recover.

Cerebral oedema

In up to 1% of cases, a very serious complication called cerebral oedema can occur. This is where excess fluid builds up inside the brain.

It's most often seen in children and young adults, and is the leading cause of death in people with diabetic ketoacidosis in this age group. Around one in every four cases is fatal.

Symptoms of cerebral oedema include:

  • headache
  • drowsiness
  • restlessness and irritability
  • facial paralysis (palsy)
  • seizures (fits)

A person with cerebral oedema will be admitted to an intensive care unit (ICU) and treated with a medication called mannitol, which helps to reduce the swelling of the brain.

Acute respiratory distress syndrome

The rapid and unpredictable changes in fluid levels that can occur in diabetic ketoacidosis can occasionally result in the lungs becoming filled with fluid.

This is known as acute respiratory distress syndrome (ARDS) and can cause serious breathing difficulties.

If you develop ARDS, a ventilator can be used to help you breathe until your condition stabilises.

Preventing diabetic ketoacidosis

If you've been diagnosed with diabetes, it's very important that you follow all recommendations regarding diet, medication, insulin therapy and self-testing to help prevent diabetic ketoacidosis.

You should also take extra precautions while you're ill, because illness can cause your blood sugar level to rise or fall to dangerous levels.

What to do while you're ill

If you need to take insulin to control your diabetes, you should have previously received instructions about looking after yourself when you're ill - known as your "sick day rules". Contact your diabetes care team or GP for advice if you haven't received these.

The advice you're given will be specific to you, but some general measures that your sick day rules may include could be to:

  • keep taking your insulin - it's very important not to stop treatment when you're ill; your treatment plan may state whether you need to temporarily increase your dose
  • test your blood sugar level more often than usual - most people are advised to check the level at least four times a day (see below)
  • keep yourself well hydrated - make sure you drink plenty of sugar-free drinks
  • keep eating - eat solid food if you feel well enough to, or liquid carbohydrates such as milk, soup and yoghurt if this is easier
  • check your ketone levels if your blood sugar level is high (see below)

Seek advice from your diabetes care team or GP if your blood sugar and/or ketone level remains high after taking insulin, if you're not sure whether to make any changes to your treatment, if you develop symptoms of diabetic ketoacidosis, or if you have any other concerns.

Checking your blood sugar and ketone levels

Simple finger prick blood test devices can be used to monitor your blood glucose levels.

Your diabetes care team should advise you about the level you should aim for and when you need to adjust your treatment or seek medical advice, but generally a reading of 11 mmol/l or more is a sign that you're at risk of diabetic ketoacidosis and should check your ketone level if you feel ill.

Ketone levels can be checked using urine test strips available on prescription, although it can take a few hours for ketones to show up in your urine. Many newer blood glucose monitors are also able to monitor blood ketone levels more quickly. Your diabetes care team will be able to provide you with more information on this.

Again, you should be advised about what a dangerous level of ketones is, but generally a reading of 2+ or more on urine strips or 0.6 mmol/l or more in your blood is a sign that you're at risk of diabetic ketoacidosis.

Contact your diabetes care team or GP immediately if you have persistently high or rising blood sugar and ketone levels. Go to your nearest accident and emergency (A&E) department if you develop severe symptoms of diabetic ketoacidosis.

 
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