Diabetic ketoacidosis: symptoms, causes and treatment

Diabetic ketoacidosis is a metabolic disease. It is a complication of type 1 diabetes in particular. A lack of insulin prevents glucose from entering the cell properly, causing blood glucose to rise. You need glucose for energy metabolism. Due to the lack of glucose in the cells, your body breaks down other tissues to act as an energy source, causing a build-up of ketones, a type of acid. The body therefore becomes more acidic (acidosis). With diabetic ketoacidosis you have very high blood sugar levels. Ketones can be found in the blood and acetone can be found in the urine. Symptoms include vomiting, abdominal pain and labored breathing. If there is ketoacidosis, you must quickly go to a doctor or hospital to receive insulin, fluids and salts. If ketoacidosis is not treated in time, it can lead to a life-threatening situation.

  • What is diabetic ketoacidosis?
  • Who gets it?
  • Symptoms
  • Complications
  • Causes of diabetic ketoacidosis
  • Triggering factors
  • Examination and diagnosis
  • Urine and blood tests
  • Determining values
  • Treatment of diabetic ketoacidosis
  • Prevention
  • Prognosis


What is diabetic ketoacidosis?

Diabetic ketoacidosis is a metabolic imbalance due to a lack of insulin. The spectrum of the disease ranges from a mild ketoacidotic metabolic imbalance to the most severe diabetic ketoacidosis with diabetic coma.
If the body does not have insulin available, the body cells cannot absorb glucose from the blood. On the one hand, this causes blood sugar levels to rise sharply, and on the other hand, the body cells have no glucose available for energy production. Therefore, they change metabolism and get energy by breaking down fatty acids. However, through this route, so-called ketones and acids accumulate in the body. The body can compensate for this to a certain extent. However, if insulin deficiency persists, this disrupted metabolism can lead to unconsciousness or coma and even death.

Who gets it?

People with type 1 diabetes are particularly affected by diabetic ketoacidosis. In approximately one third of patients who develop type 1 diabetes, the disease is not recognized until diabetic ketoacidosis has developed. Small children in particular suffer from this. In type 1 diabetes, ketoacidosis can also develop if too little insulin is accidentally injected (in relation to the need). The disease only occurs in exceptional cases in patients with type 2 diabetes.


Excessive thirst and frequent urination, as well as fatigue in people with type 1 diabetes, may indicate that diabetic ketoacidosis is developing. Nausea and vomiting, loss of appetite and (severe) abdominal pain are also typical complaints. Children with type I diabetes in particular can develop diabetic ketoacidosis, but patients with type 2 diabetes or gestational diabetes can also develop it.
Over time, diabetic ketoacidosis leads to dehydration (lack of fluid) due to the large amount of urine; if there is a severe lack of moisture, the skin looks wrinkled, the lips dry and cracked. This is accompanied by symptoms such as dizziness, fatigue, drowsiness or loss of consciousness. The overacidification and accumulation of ketones in the blood leads to an altered breathing pattern (very deep, slow breaths) and a fruity-smelling exhaled air (acetone odor).


The patient will only recover if the symptoms are recognized in time and treatment can be started immediately. Insufficient treatment can cause permanent damage to the kidneys, heart, brain, etc. Because the circulatory system in diabetic ketoacidosis fails very quickly, many patients fall into a coma, most of whom recover only partially.

Causes of diabetic ketoacidosis

Diabetic ketoacidosis occurs when the body lacks the hormone insulin. Then the blood sugar level rises because the body cells cannot absorb the glucose from the blood. The usual vital energy production from glucose can no longer take place. To maintain energy supply, the body burns fat. This leads to an increase in acidity in the body (the blood becomes acidic, the pH drops) and ketones are formed.
High blood sugar also causes fluid to be drawn from the tissues into the blood, which in turn causes a significant increase in urine production, leading to loss of body fluid (dehydration). Sugar in the urine also helps to remove more fluid from the body (osmotic diuresis: increased urine production with large amounts of solutes present in the urine).

Triggering factors

If type 1 diabetes develops slowly in a child and is not detected quickly enough, diabetic ketoacidosis can occur suddenly; a medical emergency then occurs.
A common cause of ketoacidosis in already diagnosed diabetes is too low a dose of insulin when there is an increased need. The reason for this could be an infection, such as a urinary tract infection or pneumonia. Infections increase the need for insulin. If patients do not then increase the insulin dose, ketoacidosis may occur. So if diabetics have had a fever for a few days or experience diarrhea or vomiting for several hours, they are at risk of developing ketoacidosis if the insulin dose is not adjusted quickly. Insulin administration must also be carefully adjusted during surgery in people with diabetes, so that metabolic disorders do not occur. Other causes include pancreatitis or an underactive thyroid gland.
In people with type 2 diabetes, excessive alcohol consumption or serious infections can cause ketoacidosis. In most patients with type 2 diabetes, the pancreas can still produce small amounts of insulin, so the risk of ketoacidosis is not as high as with type 1 diabetes. Yet there are also people with type 2 who produce virtually no insulin themselves, which of course increases the risk of ketoacidosis if they do not perform the correct insulin treatment.

Examination and diagnosis

Urine and blood tests

Diabetic ketoacidosis is diagnosed by a doctor. The blood sugar level is determined at the start. In addition, the amount of glucose and ketones in the urine is determined. In addition, the pH value of the blood is measured, as well as the sodium and potassium values and blood gases. Diabetic ketoacidosis can also be recognized by the affected person’s breath as it smells strongly of acetone (similar to the smell of nail polish remover).

Determining values

In diabetic ketoacidosis there is an increase in blood sugar levels to values of > 13.9 mmol/l (hyperglycemia, which means that the blood glucose level is too high) as well as a high concentration of ketones in the blood (ketonemia) or in the urine (ketonuria ) and hyperacidity or acidification of the blood (pH <7.3) and low levels of bicarbonate (<15 mmol/l), an essential acid buffer of the blood in the body. Then the typical complaints occur as described above.

Dehydration can be serious in diabetic ketoacidosis and intravenous fluids are usually needed as part of treatment. / Source: Harmid, Wikimedia Commons (Public domain)

Treatment of diabetic ketoacidosis

Diabetic ketoacidosis is a potentially life-threatening condition and requires immediate treatment. There is always significant dehydration (loss of fluid) and therefore hydration will be started first. This also lowers blood sugar levels. Insulin is given little by little to further lower blood sugar levels. Many patients also suffer from severe potassium loss, which results in potassium being administered. Severe acidosis (excessive acidity in the blood) can also occur, which is why bicarbonate is sometimes given.
During treatment, in severe cases this will take place in intensive care, the patients are closely monitored and various blood values are regularly determined for the accurate administration of insulin, glucose, potassium, bicarbonate, etc. The aim is to gradually reduce the restore normal blood levels; Too rapid compensation can lead to life-threatening cerebral edema.


Patients should work closely with their doctor to develop a plan to manage high blood sugar levels. How much should the insulin dose be increased? If such a situation arises and you are not sure what to do, contact your doctor immediately to discuss.
You need to pay extra attention to your blood sugar levels if you are affected by illness. Then you should check your blood sugar level more often than normal, at least once every 4 hours (and more often if your blood sugar level is fluctuating considerably).
Take the following measures to prevent diabetic ketoacidosis:

  • take your diabetes medication as prescribed by the doctor
  • follow your meal plan (with diabetes it is important to make a healthy choice, from breakfast to dinner) and stay hydrated by drinking enough (water)
  • monitor your blood sugar levels consistently and if you notice a problem, talk to your doctor about adjusting your treatment plan
  • try to avoid illness or infection
  • check your ketone levels in the urine during illness or after an injury



Diabetic ketoacidosis can be a life-threatening complication of diabetes. If you do not receive appropriate treatment immediately, it can lead to kidney failure, cardiac arrest or even death. It is vital that diabetics, as well as their loved ones, are aware of the warning signs. The sooner you are treated, the greater the chance of full recovery.

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  • Diabetes, short-term consequences: symptoms and types
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