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For further information, see CMDT Part 27-03: Diabetic Ketoacidosis

Key Features

Essentials of Diagnosis

  • Hyperglycemia > 250 mg/dL (13.9 mmol/L)

  • Acidosis with blood pH < 7.3

  • Serum bicarbonate < 15 mEq/L

  • Serum positive for ketones

General Considerations

  • May be the initial manifestation of type 1 diabetes

  • Commonly occurs with poor compliance in type 1 diabetics, particularly when episodes are recurrent

  • Develops in type 1 diabetics with increased insulin requirements during infection, trauma, myocardial infarction, or surgery

  • May develop in type 2 diabetics under severe stress such as sepsis or trauma

  • Common serious complication of insulin pump therapy


  • Incidence is 5 to 8 episodes per 1000 diabetic persons annually

  • Incidence in insulin pump therapy is 1 per 80 patient-months of treatment

Clinical Findings

Symptoms and Signs

  • May begin with a day or more of polyuria, polydipsia, marked fatigue, nausea and vomiting and, finally, mental stupor that can progress to coma

  • Drowsiness is fairly common but frank coma only occurs in about 10% of patients

  • Dehydration, possible stupor

  • Rapid deep breathing and a "fruity" breath odor of acetone

  • Hypotension with tachycardia indicates profound fluid and electrolyte depletion

  • Mild hypothermia usually present; elevated or even a normal temperature may suggest infection

  • Abdominal pain and tenderness in the absence of abdominal disease; conversely, cholecystitis or pancreatitis may occur with minimal symptoms and signs

Differential Diagnosis

  • Lactic acidosis in type 1 diabetics, including the use of metformin

  • Alcoholic ketoacidosis

  • Hypoglycemia

  • Hyperglycemic hyperosmolar state

  • Uremia

  • Starvation ketoacidosis

  • Salicylate poisoning


Laboratory Tests

  • Plasma glucose of 350–900 mg/dL (19.4–50 mmol/L)

  • Serum ketones at a dilution of 1:8 or greater or β-hydroxybutyrate more than 4 nmol/L

  • Hyperkalemia (serum potassium level of 5–8 mEq/L)

  • Mild hyponatremia (serum sodium of approximately 130 mEq/L)

  • Hyperphosphatemia (serum phosphate level of 6–7 mg/dL [1.9–2.3 mmol/L])

  • Elevated blood urea nitrogen and serum creatinine levels

  • Acidosis may be severe (pH ranging from 6.9 to 7.2, and serum bicarbonate ranging from 5 mEq/L to 15 mEq/L)

  • PCO2 is low (15–20 mm Hg) related to hyperventilation

  • Fluid depletion is marked, typically about 100 mL/kg

  • Acetoacetic acid is measured by nitroprusside reagents [Acetest and Ketostix]; the more prevalent β-hydroxybutyric acid has no ketone group and is therefore not detected by conventional nitroprusside tests

  • Nonspecific elevations of serum amylase and lipase occurs in about 16–25 % of cases of diabetic ketoacidosis; an imaging study may be necessary if the diagnosis of acute pancreatitis is being seriously considered

  • Serum lipase may be useful if the diagnosis of pancreatitis is being seriously considered

  • Leukocytosis up to 25,000/mcL (25 × 109/L) with a left shift may occur with or without associated infection

  • Hyperchloremic ...

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