What are the signs of diabetic ketoacidosis (DKA)?

Signs of Diabetic Ketoacidosis (DKA)

DKA presents with a classic triad of symptoms and signs: polyuria, polydipsia, and polyphagia, accompanied by nausea/vomiting, abdominal pain, Kussmaul respirations (deep and rapid breathing), altered mental status, and dehydration. 1

Clinical Presentation Timeline

The evolution of DKA symptoms typically occurs within 24 hours in most patients, though some may develop symptoms over several days. 1 Occasionally, patients present acutely with no prior warning symptoms. 1

Cardinal Symptoms

Early Symptoms (Most Common)

• Polyuria (excessive urination) 1, 2
• Polydipsia (excessive thirst) 1, 2
• Polyphagia (excessive hunger) 1
• Weight loss 1, 2
• Severe fatigue 2

Gastrointestinal Symptoms

• Nausea and vomiting (present in up to 25% of patients; may be coffee-ground in appearance and guaiac positive due to hemorrhagic gastritis) 1
• Abdominal pain (specific to DKA, not seen in HHS) 1, 2
• Loss of appetite 3

Respiratory Signs

• Kussmaul respirations (deep, rapid, labored breathing pattern) 1, 4
• Fruity odor on breath (acetone breath) 3
• Dyspnea 2

Physical Examination Findings

Cardiovascular Signs

• Tachycardia (rapid pulse) 1, 3, 4
• Hypotension 1, 4
• Shock (in severe cases) 1

Neurological Signs

• Altered mental status ranging from full alertness to profound lethargy 1, 5
• Clouding of sensorium 1
• Confusion or disorientation 3
• Coma (more frequent in HHS but can occur in severe DKA) 1

Dermatologic Signs

• Poor skin turgor (indicating dehydration) 1
• Flushed face 3
• Dry skin 3

Temperature Abnormalities

• Normothermia or hypothermia (despite infection being a common precipitant; hypothermia is a poor prognostic sign) 1

Severity-Specific Features

Mild DKA

• Drowsy feeling 3
• pH 7.25-7.30 1
• Anion gap >10 mEq/L 6

Moderate to Severe DKA

• Heavy breathing 3
• Rapid pulse 3
• Lethargy (especially with pH <7.0) 5
• Anion gap >12 mEq/L 6

Life-Threatening Signs

• Prolonged hyperglycemia leading to:
  • Nausea and vomiting 3
  • Stomach pain 3
  • Dehydration 3
  • Loss of consciousness 3
  • Death (if uncorrected) 3

Laboratory Confirmation

While clinical signs guide initial suspicion, diagnosis requires laboratory confirmation with the DKA triad: 7

• Hyperglycemia (blood glucose >250 mg/dL, though euglycemic DKA can occur) 1, 2
• Metabolic acidosis (pH <7.3, bicarbonate <18 mEq/L, anion gap >10 mEq/L) 1, 6, 2
• Elevated ketones (serum or urine) 1, 2, 7

Critical Pitfalls

Euglycemic DKA is an increasingly recognized presentation where glucose levels may be normal or even low (<200 mg/dL), particularly in patients taking SGLT-2 inhibitors. 2, 8 Clinicians must maintain high suspicion for DKA based on acidosis and ketosis regardless of glucose levels. 8

Preceding febrile illness is common, and infection is the most frequent precipitating factor. 1, 2 However, patients may be normothermic or hypothermic despite active infection. 1