What are the symptoms of Diabetic Ketoacidosis (DKA)?

From the Guidelines

Diabetic ketoacidosis (DKA) symptoms include excessive thirst, frequent urination, nausea, vomiting, abdominal pain, weakness, fatigue, confusion, fruity-scented breath, and rapid breathing, and require immediate medical attention to prevent life-threatening complications 1. These symptoms typically develop quickly, often within 24 hours. The hallmark signs of DKA are:

• High blood glucose levels (typically above 250 mg/dL)
• The presence of ketones in urine or blood
• Metabolic acidosis Physical examination may reveal signs of dehydration such as:
• Dry mucous membranes
• Reduced skin turgor
• Low blood pressure Patients may also experience Kussmaul respirations (deep, labored breathing) as the body attempts to compensate for metabolic acidosis by exhaling more carbon dioxide. DKA occurs when the body cannot use glucose for energy due to insufficient insulin, causing it to break down fat for fuel instead, which produces ketones. The management goals for DKA include restoration of circulatory volume and tissue perfusion, resolution of hyperglycemia, and correction of electrolyte imbalance and acidosis, and should be individualized based on a careful clinical and laboratory assessment 1. In critically ill and mentally obtunded individuals with DKA, continuous intravenous insulin is the standard of care, and successful transition from intravenous to subcutaneous insulin requires administration of basal insulin 2–4 h before the intravenous insulin is stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia 1. There is no significant difference in outcomes for intravenous human regular insulin versus subcutaneous rapid-acting analogs when combined with aggressive fluid management for treating mild or moderate DKA 1. The use of bicarbonate in patients with DKA is generally not recommended, as it has been shown to make no difference in the resolution of acidosis or time to discharge 1.

From the FDA Drug Label

The first symptoms of DKA usually come on gradually, over a period of hours or days, and include a drowsy feeling, flushed face, thirst, loss of appetite, and fruity odor on the breath. With DKA, blood and urine tests show large amounts of glucose and ketones. Heavy breathing and a rapid pulse are more severe symptoms If uncorrected, prolonged hyperglycemia or DKA can lead to nausea, vomiting, stomach pain, dehydration, loss of consciousness, or death.

The symptoms of Diabetic Ketoacidosis (DKA) include:

• A drowsy feeling
• Flushed face
• Thirst
• Loss of appetite
• Fruity odor on the breath
• Heavy breathing
• Rapid pulse
• Nausea
• Vomiting
• Stomach pain
• Dehydration
• Loss of consciousness 2

From the Research

DKA Symptoms

• The symptoms of diabetic ketoacidosis (DKA) include polyuria with polydipsia (98 percent), weight loss (81 percent), fatigue (62 percent), dyspnea (57 percent), vomiting (46 percent), preceding febrile illness (40 percent), abdominal pain (32 percent), and polyphagia (23 percent) 3.
• DKA can occur in persons of all ages, with 14 percent of cases occurring in persons older than 70 years, 23 percent in persons 51 to 70 years of age, 27 percent in persons 30 to 50 years of age, and 36 percent in persons younger than 30 years 3.
• A diagnosis of DKA is confirmed when all of the three criteria are present - 'D', either elevated blood glucose levels or a family history of diabetes mellitus; 'K', the presence of high urinary or blood ketoacids; and 'A', a high anion gap metabolic acidosis 4.
• Common precipitating factors of DKA include insulin deficiency, infection, and other illnesses 5.
• The case fatality rate for DKA is 1 to 5 percent, and about one-third of all cases are in persons without a history of diabetes mellitus 3.

Diagnostic Criteria

• DKA is characterized by a serum glucose level greater than 250 mg per dL, a pH less than 7.3, a serum bicarbonate level less than 18 mEq per L, an elevated serum ketone level, and dehydration 3.
• Measurement of A1C, blood urea nitrogen, creatinine, serum glucose, electrolytes, pH, and serum ketones; complete blood count; urinalysis; electrocardiography; and calculation of anion gap and osmolar gap can differentiate DKA from hyperosmolar hyperglycemic state, gastroenteritis, starvation ketosis, and other metabolic syndromes, and can assist in diagnosing comorbid conditions 3.

Treatment and Management

• The mainstays of treatment for DKA include restoration of circulating volume, insulin therapy, electrolyte replacement, and treatment of any underlying precipitating event 4.
• Appropriate treatment includes administering intravenous fluids and insulin, and monitoring glucose and electrolyte levels 3.
• Low-dose continuous intravenous insulin therapy is as effective as high-dose therapy, and bicarbonate administration is probably unnecessary 6.
• Potassium replacement is almost always necessary, often requiring massive amounts of this ion due to the total body depletion seen with the development of ketoacidosis 5.