What are the symptoms of diabetic ketoacidosis (DKA)?

Diabetic Ketoacidosis Symptoms

Diabetic ketoacidosis presents with polyuria, polydipsia, weight loss, dehydration, nausea, vomiting, abdominal pain, and Kussmaul respiration (deep, rapid breathing), typically developing over hours to days. 1

Cardinal Symptoms

The classic triad of symptoms includes:

• Polyuria (excessive urination) and polydipsia (excessive thirst) occur due to osmotic diuresis from hyperglycemia, leading to significant fluid losses 1
• Weight loss develops rapidly as the body breaks down fat and muscle for energy in the absence of adequate insulin 1
• Dehydration is a prominent physical finding resulting from osmotic diuresis and fluid losses 1

Gastrointestinal Manifestations

• Nausea and vomiting are present in many patients and can be severe enough to prevent oral intake 1, 2
• Abdominal pain occurs frequently and may mimic an acute surgical abdomen, potentially leading to diagnostic confusion 1
• These gastrointestinal symptoms result from metabolic acidosis and ketone accumulation 2

Respiratory Signs

• Kussmaul respiration (deep, rapid breathing) is characteristic of DKA and represents the body's attempt at respiratory compensation for metabolic acidosis 1
• Patients may have a fruity breath odor from acetone, though this is not always detectable 3

Neurological Symptoms

• Mental status changes range from alertness in early stages to lethargy, drowsiness, and confusion as the condition worsens 1, 3
• Altered mental status is a red flag requiring immediate medical attention 1
• Patients are usually alert initially, but deterioration indicates worsening severity 1

Timeline and Progression

• DKA develops over hours to days, which is faster than hyperglycemic hyperosmolar state (HHS) that develops over days to weeks 1
• The rapid onset distinguishes DKA from other diabetic complications 1

Special Clinical Scenarios

Euglycemic DKA

• Approximately 10% of DKA cases present with blood glucose <200 mg/dL (11.1 mmol/L), making diagnosis challenging 4, 3
• This occurs particularly in:
  • Pregnancy 4, 1
  • SGLT2 inhibitor use 4
  • Reduced food intake or prolonged fasting 4
  • Alcohol use 4
  • Liver failure 4

Pregnancy-Related Considerations

• Pregnant individuals may present with euglycemic DKA, and diagnosis can be complicated by mixed acid-base disturbances, especially with hyperemesis 4, 1
• Up to 2% of pregnancies with pregestational diabetes (most often type 1 diabetes) are complicated by DKA 4

Additional Physical Findings

• Hypothermia can occur despite the presence of infection 2
• Hypotension results from severe volume depletion 3, 2
• Tachycardia is common due to dehydration and metabolic stress 2

Critical Warning Signs Requiring Immediate Medical Attention

Patients should seek emergency care if they experience:

• Inability to tolerate oral hydration 1
• Blood glucose levels that do not improve with insulin administration 1
• Altered mental status 1
• Any signs of worsening illness 1
• Persistent vomiting 1

Common Pitfalls

• Do not dismiss symptoms in patients with normal or mildly elevated glucose levels, as euglycemic DKA can occur 3
• Abdominal pain may be mistaken for a surgical emergency, delaying appropriate DKA treatment 1
• Patients on SGLT2 inhibitors require heightened suspicion for DKA even with normal glucose levels 4

Patient Education Points

• Individuals at risk should measure urine or blood ketones when experiencing symptoms and potential precipitating factors (illness, missed insulin doses), particularly if glucose exceeds 200 mg/dL 4
• Contact the diabetes care team immediately when concerned about or experiencing DKA symptoms 4, 1
• Never stop basal insulin even when not eating, as this can precipitate DKA 4