History and exam
Key diagnostic factors
common
known diabetes or features of diabetes
Consider diabetic ketoacidosis (DKA) in:
Patients with known diabetes who are unwell[2][20][63]
DKA is most common in people with type 1 diabetes but can also present in those with type 2 diabetes.[2]
Patients with features of diabetes (increased thirst, polyuria, recent unexplained weight loss, or excessive tiredness) AND any of the following:[20][11][63][65][66]
Nausea
Vomiting
Abdominal pain
Hyperventilation (Kussmaul respiration)
Dehydration (signs include dry mucous membranes, tachycardia, decreased skin turgor, slow capillary refill, and hypotension)
Reduced consciousness
nausea and/or vomiting
abdominal pain
Examine the abdomen for a possible cause of diabetic ketoacidosis (DKA), such as pancreatitis.[42][64] DKA can both cause and mimic an acute abdomen.[66] Severity of abdominal pain correlates with the degree of acidosis.[1] DKA must be excluded prior to any emergency surgery.
Look for abdominal distension, which may indicate bowel obstruction.[99]
Palpate the abdomen to check for rebound tenderness and guarding caused by irritation of the peritoneum.[99]
Auscultate for bowel sounds.[100]
Hyperactive ‘tinkling’ bowel sounds may be present in early bowel obstruction.
Reduced or absent bowel sounds may be present in late bowel obstruction, perforated viscus, haemoperitoneum, or any cause of peritoneal inflammation.
Perform a rectal examination.[99]
Ensure you take a chaperone with you.
Assess for occult or frank blood, pain, or a mass.
dehydration
Check for signs of dehydration. These include:[20]
Dry mucous membranes
Decreased skin turgor or skin wrinkling
Slow capillary refill
Tachycardia with a weak pulse
Hypotension
hyperventilation (Kussmaul respiration)
reduced consciousness
Assess conscious level hourly using the Glasgow Coma Scale to monitor for cerebral oedema. Reduced consciousness is strongly associated with more severe diabetic ketoacidosis (DKA) and a worse prognosis.[2][89] [ Glasgow Coma Scale Opens in new window ]
Mental status can range from alert in mild DKA to coma in severe DKA.[67]
Cerebral oedema can develop during treatment of DKA due to rapid correction of hyperglycaemia.[2]
Signs include headache, irritability, slowing pulse, rising blood pressure, and reducing conscious level. These may occur several hours after starting treatment.[3][79]
Papilloedema is a late sign of cerebral oedema.[3]
If neurological deterioration occurs, seek urgent input from the critical care team and administer mannitol without delay.[80]
Cerebral oedema has a mortality rate of 70%. It is most common in children and adolescents but can occur rarely in adults.[63]
presence of risk factors
Infection
Discontinuation of insulin (unintentional or deliberate)
Ask sensitively about reasons for deliberate discontinuation of insulin, which may include fear of weight gain or hypoglycaemia, financial barriers, and psychological factors such as needle phobia and stress.[20][63]
Younger patients with type 1 diabetes may omit insulin due to fear of hypoglycaemia, weight gain, eating disorders, or the stress of having a chronic disease. These factors may account for 20% of episodes of recurrent DKA.[93]
Inadequate insulin
Malfunctioning insulin pen or pump.
Degradation of insulin due to storage at incorrect temperature.
New onset of diabetes[20]
A common cause of DKA.
Acute illness
Common causes include myocardial infarction, sepsis, and pancreatitis.[42]
Maintain a high level of suspicion for myocardial infarction as patients with diabetes often present with atypical symptoms.
Physiological stress
This includes pregnancy, trauma, and surgery.
Practical tip
Diagnosis of DKA in pregnancy is often delayed because it can occur at lower blood glucose levels (including euglycaemic DKA) and faster than in non-pregnant patients.[2][98]
DKA in pregnancy may present with abdominal pain; always consider as a possible alternative to pre-term or term labour.[2]
DKA usually occurs in the second and third trimesters due to increased insulin resistance.[98] Pregnant women suspected of having DKA should receive care from both the obstetric and medical (or diabetes) teams.[2]
Past medical history
History of diabetes:
DKA is most common in people with type 1 diabetes but can also occur in those with type 2 diabetes.[11]
Drug history[20]
Drugs that may cause DKA include:[6][18][21][23][26][31][47][48][49][50][70][71][73][72][74]
Corticosteroids (increase insulin resistance)
Thiazide diuretics (unclear cause but may increase insulin resistance, inhibit glucose uptake, and decrease insulin release)
Sympathomimetics, such as dobutamine and terbutaline (alter glucose metabolism)
Atypical antipsychotics, such as clozapine, olanzapine, and risperidone (alter glucose metabolism)
Immune checkpoint inhibitors (cause insulin deficiency)
Cocaine, cannabis, and acute intoxication with alcohol
Sodium-glucose cotransporter-2 (SGLT2) inhibitors (e.g., dapagliflozin, empagliflozin, canagliflozin, ertugliflozin) and the dual SGLT1/SGLT2 inhibitor sotagliflozin (prevent reabsorption of glucose and facilitate its excretion in urine)
uncommon
hypothermia
Although concomitant infection is common, patients with diabetic ketoacidosis (DKA) are usually normothermic or hypothermic due to peripheral vasodilation. Severe hypothermia is associated with a mortality rate of 30% to 60%.[90]
Practical tip
Fever is not a feature of diabetic ketoacidosis (DKA), but DKA may be caused by sepsis. Suspect sepsis as a cause of DKA if there is fever or hypothermia, (although hypothermia may also occur in patients with DKA of other aetiologies), hypotension, refractory acidosis, or lactic acidosis.[3]
Other diagnostic factors
common
acetone smell on breath
The patient’s breath smells like pear drops or nail varnish remover.[20] This is due to high ketone levels.
Practical tip
Bear in mind that a significant proportion of people are unable to smell acetone even if it is present.
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