An episode of diabetic ketoacidosis often evolves over a 24 hour period [8]. The main symptoms are nausea, vomiting, extensive thirst, excessive production of urine as well as abdominal pain. Hyperglycemia is also present most of the time. Breathing is laboured and deep in severe cases of diabetic ketoacidosis. The abdomen may be tender and in a minority of patients, vomiting of blood may be noted. The vomiting of blood is as a result of oesophageal erosion. Confusion, lethargy, stupor and ultimately coma may be seen in patients with severe cases of diabetic ketoacidosis.

Following physical examination, there is often clinical evidence of dehydration such as decreased skin turgor and presence of a dry mouth. In small children with diabetic ketoacidosis, cerebral edema may be presented and when this is present, headache, coma and loss of pupillary light reflex are also seen.

• Fatigue

  A 46-year-old woman with a history of Graves' disease presented with the chief complaints of appetite loss, weight loss, fatigue, nausea, and sweating. She was diagnosed with diabetic ketoacidosis (DKA), thyroid storm, and influenza A. [ncbi.nlm.nih.gov]

  Symptoms associated with low potassium include fatigue, muscle weakness, muscle cramps and an irregular heart rhythm. Severely low potassium can lead to life-threatening heart rhythm abnormalities. [livestrong.com]

  Most are mild and might be a problem with all diabetes medications, including: Yeast infection Urinary tract infection Nausea Fatigue Photosensitivity Increased LDL (bad) cholesterol One of the biggest concerns for Invokana users is the drug’s link to [drugdangers.com]

  […] kidneys try to rid the body of excess glucose, and water is excreted along with the glucose High blood glucose (sugar) levels The presence of ketones in the urine Other signs and symptoms of ketoacidosis occur as the condition progresses: These include: Fatigue [medicinenet.com]

• Unconsciousness

  If not treated, people with ketoacidosis can become unconscious. DKA usually occurs in people with type 1 diabetes. It is rare in type 2 diabetes. [healthdirect.gov.au]

  An unconscious diabetic patient. Postgrad Med J. 1998;74:549–50. CrossRef PubMed Google Scholar 11. Guerin JM, Meyer P, Segrestaa JM. Hypothermia in diabetic ketoacidosis. Diabetes Care. 1987;10:801–2. PubMed Google Scholar 12. Ritchie S, Waugh D. [dx.doi.org]

• Poor Growth

  She has underlying delayed development, seizures, optic atrophy and poor growth. An initial diagnosis of DKA was made and standard treatment was started. [ncbi.nlm.nih.gov]

  Chronic undertreatment with insulin with resultant long-standing poor diabetes control often leads to poor growth and weight loss and a delay in pubertal and skeletal maturation. Overtreatment with insulin can lead to excessive weight gain. [care.diabetesjournals.org]

• Kussmaul Respiration

  He was tachypneic with a respiratory rate of 35/minute; the pattern was characteristic of Kussmaul's respiration. There was subcutaneous emphysema in both supraclavicular areas. [casesjournal.biomedcentral.com]

  Respiratory compensation of acidosis can lead to tachypnoea or Kussmaul respiration (very deep, slowly rhythmic breathing). Examine the chest for signs of pneumonic consolidation. [patient.info]

  Her initial assessment revealed tachypnea with Kussmaul's respiration, tachycardia and moderate dehydration, with an estimated fluid deficit of 6%– 9%. [dx.doi.org]

  The deep and rapid sighing respiration, called Kussmaul's respiration, in patients suffering DKA provides clinical evidence of this compensatory mechanism. [acutecaretesting.org]

• Tachypnea

  On initial evaluation, our patient had profound encephalopathy, with marked tachypnea and work of breathing. Arterial blood gas revealed a pH of 6.9, pCO2 of 20 and a bicarbonate level of 5. [ncbi.nlm.nih.gov]

  Her initial assessment revealed tachypnea with Kussmaul's respiration, tachycardia and moderate dehydration, with an estimated fluid deficit of 6%– 9%. [dx.doi.org]

  Tachypnea with Kussmal's breathing is universal when severe metabolic acidosis is present. The breath also has a characteristic ketone odor. [clinicaladvisor.com]

  Tachypnea/kussmaul Nausea/vomiting Thirst/polyuria Abdominal pain Shortnessof Tachycardia breath respirations/respiratory distress Fruity odour in breath. [slideshare.net]

• Nausea

  It is caused by an interaction of existing and worsening acidosis due to nausea and vomiting by a precipitating illness. [ncbi.nlm.nih.gov]

• Abdominal Pain

  Although DKA that presented to the ED with complaint of abdominal pain is not uncommon, it is precipitated by hyperthyroidism, which is rare and more complicated. [ncbi.nlm.nih.gov]

  There was no significant correlation between pancreatic enzyme elevation and abdominal pain. [dx.doi.org]

• Polydipsia

  Notable findings on admission were a ventricular rate of 235 beats/min, tachypnoea, tremors, polydipsia and a lack of fever. Due to the unusual constellation of symptoms, diagnosis was only possible after initial laboratory results came back. [ncbi.nlm.nih.gov]

  In individuals who have no previous diagnosis of diabetes mellitus, a preceding history of polyuria, polydipsia, and weight loss usually can be elicited. With significant ketosis, patients may have a fruity breath. [pedsinreview.aappublications.org]

• Suprapubic Pain

  CONCLUSIONS: Nephrolithiasis is a rare complication of pediatric DKA, and should be considered in children with DKA who develop hematuria, flank pain, or suprapubic pain. [ncbi.nlm.nih.gov]

• Ketotic Breath

  General findings in diabetic ketoacidosis On examination, general findings of DKA may include the following: Ill appearance Dry skin Labored respiration Dry mucous membranes Decreased skin turgor Decreased reflexes Characteristic acetone (ketotic) breath [emedicine.com]

• Stupor

  Confusion, lethargy, stupor and ultimately coma may be seen in patients with severe cases of diabetic ketoacidosis. [symptoma.com]

  The main symptoms of DKA include: Heavy or laboured breathing Nausea and vomiting Excessive thirst Stomach pains Stupor or unconsciousness What should I do? If you are experiencing these symptoms you must go to hospital immediately. [jdrf.org.uk]

  On physical examination, evidence of dehydration in a stuporous patient with rapid deep breathing and a "fruity" breath odor of acetone would strongly suggest the diagnosis. [health.am]

  /coma Stupor/coma TABLE 2 Diagnostic Criteria for Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State Mild DKA Moderate DKA Severe DKA HHS Plasma glucose (mg per dL [mmol per L]) 250 (13.9) 250 250 600 (33.3) Arterial pH 7.25 to 7.30 7.00 to 7.24 [aafp.org]

• Agitation

  This may be subtle and include agitation, confusion and delirium. An early warning of cerebral edema is a progressive rise in pCO2 if pH fails to increase. [clinicaladvisor.com]

  Compare insulin shock. observations The person appears flushed; has hot, dry skin; is restless, uncomfortable, agitated, and diaphoretic; and has a fruity odor to the breath. Nausea, confusion, and coma are often noted. [medical-dictionary.thefreedictionary.com]

  On examination, she was agitated but conscious and was afebrile, with an increased respiratory rate of 25 breaths/min. [cfp.ca]

  Symptoms of diabetic ketoacidosis may include: excessive thirst; increased urination; tiredness or weakness; a flushed appearance, with hot dry skin; nausea and vomiting; dehydration; restlessness, discomfort and agitation; fruity or acetone smelling [mydr.com.au]

  Paresthesias, tremor, carpopedal spasm, agitation, seizures, and cardiac dysrhythmias all are reported symptoms. Checking magnesium levels and correcting low levels should be considered in patients with DKA. [aafp.org]

• Fluctuating Level of Consciousness

  Headache and fluctuating level of consciousness herald this complication in some patients, but respiratory arrest is the initial manifestation in others. [merckmanuals.com]

• Polyuria

  The patient was treated without dialysis and was cured after a polyuria period of 2 months after the oliguric period. [dx.doi.org]

  The patient developed polydipsia and polyuria one week before admission. The initial blood glucose level was 1136 mg/dL and severe acidosis was present (pH 7.1; BE-25.9). [ncbi.nlm.nih.gov]

• Dark Urine

  It is characterized by triad of muscle weakness, myalgia and dark urine and is associated with increased creatine kinase and lactate dehydrogenase. [ncbi.nlm.nih.gov]

The condition is diagnosed when the combination of hyperglycemia, acidosis and ketones in the blood is demonstrated [9]. To demonstrate acidosis, arterial blood gas measurement is often performed. Ketones can be measured in the blood and urine.

Also, blood samples may be taken to measure urea and creatinine (important measures of kidney function) as well as electrolytes. Other tests to rule out infection and acute pancreatitis may be carried out. Some of the tests include, complete blood count, C-reactive protein, etc.

• Nephrolithiasis

  All three patients with nephrolithiasis were males with new onset type 1 diabetes, aged 11 to 16.5 years. They all developed symptoms of nephrolithiasis after transition to subcutaneous insulin. [ncbi.nlm.nih.gov]

• Hyponatremia

  Halperin reports holding a patent on the use of sodium-linked glucose transporter 2 inhibitors to increase the excretion of water in patients with hyponatremia (US 8,518,895,B2) and a pending patent application on the use of sodium-linked glucose transporter [nejm.org]

  Other laboratory abnormalities include hyponatremia, elevated serum creatinine, and elevated plasma osmolality. [merckmanuals.com]

  High serum osmolarity also drives water from intracellular to extracellular space, causing dilutional hyponatremia. Sodium also is lost in the urine during the osmotic diuresis. [emedicine.com]

• Bicarbonate Decreased

  decreased to 15–18 mmol/l (normal above 20); the person is alert Moderate: pH 7.00–7.25, bicarbonate 10–15, mild drowsiness may be present Severe: pH below 7.00, bicarbonate below 10, stupor or coma may occurA 2004 statement by the European Society for [en.wikipedia.org]

• Peaking T Wave

  He presented in hyperglycemic, hyperosmolar, hyperketotic state with hyperkalemia, and peaked T waves on electrocardiogram. He was treated with vigorous intravenous hydration, insulin, and kaexylate which stabilized his metabolic profile. [ncbi.nlm.nih.gov]

  An ECG can be of help in monitoring the patient's potassium status: High peaked T waves are a sign of hyperkalemia, and flattened T waves with U waves are a sign of hypokalemia. [health.am]

People who are diagnosed with diabetic ketoacidosis are either treated in the emergency room or admitted to the hospital [10]. Treatment if often based on a three pronged approach covering the following:

• Fluid replacement
• Electrolyte replacement
• Insulin therapy

For diabetic ketoacidosis, the overall rate of mortality is 2% or less. However, prognosis is poor when there is presence of deep coma at the time of diagnosis is made [7].

In properly treated patients, prognosis is excellent, especially in younger patients who do not have any forms of intercurrent infections. The worst prognosis is seen in older patients with illnesses such as myocardial infarction, sepsis or pneumonia who are treated outside an intensive care unit.

In diabetic ketoacidosis, the most common scenarios are underlying or concomitant infection (seen in 40% of cases), missed insulin treatments (seen with 25% of cases) or newly diagnosed or unknown diabetes (seen in 15% of cases) [2]. There are other etiologic factors for this condition.

In type 1 diabetes mellitus, the following are etiologic factors [3]:

• Acute insulin deficiency
• Poor compliance with insulin mostly through injection omissions or lack of patient education
• Urinary tract infection (UTI) and other bacterial infections, recurrent sicknesses
• Stress (emotional, surgical or medical)
• Idiopathic causes
• Blockage of insulin infusion catheter pump
• Mechanical failure of the insulin infusion pump

In type 2 diabetes, the main etiologic factors are:

• Intercurrent illnesses such as myocardial infarction or pneumonia
• Medication use (Clozapine, pentamidine, corticosteroids)

4.6 to 8.0 per 100 people with type 1 diabetes develop this condition each year. In the United States, over 135,000 hospital admissions happen each year as a result of diabetic ketoacidosis [4]. The estimated cost has been put at $2.4 billion, around a quarter of what it costs to take care of people with type 1 diabetes. The number of cases in the United States has been on the increase. The risk is higher in people who have eating disorders and those who are unable to afford insulin.

In developed countries, the incidence of diabetic ketoacidosis remains unknown. However, it may be higher in industrialised nations [5].

A racial predisposition towards whites is notable with this condition and this as a result of the fact that type 1 diabetes is mostly seen in this racial group.

Diabetic ketoacidosis refers to a complex disordered metabolic state which is most of the time characterised by hyperglycemia, ketonuria and ketoacidosis [6]. DKA often occurs as a result of absolute or relative insulin deficiency which is followed most of the time by an increase in counter-regulatory hormones such as glucagon, cortisol, epinephrine and growth hormone. This kind of hormonal imbalance is referred to as glycogenolysis and lipolysis.

Severe hyperglycemia is caused by hepatic gluconeogenesis, glycogenolysis and excessive counter regulatory hormone. Lipolysis on the other hand causes an increase in serum free fatty acids. Hepatic metabolism of free fatty acids alternative source of energy or ketogenesis leads to accumulation of acidic intermediate and end metabolites such as ketones and ketoacids. The ketones formed include acetoacetate, acetone and beta-hydroxybutyrate.

There are important steps to be taken if diabetic ketoacidosis is to be dealt with. This includes the following:

• Commitment to the management of diabetes 
• Continuous monitoring of blood sugar level 
• Adjustment of insulin dosage as needed
• Consistent check of ketone levels

Diabetic ketoacidosis (DKA) is a complication of diabetes that is often life-threatening [1]. The condition is an acute one and it is mainly seen in people with the type 1 diabetes. It is however not rare in patients with type 2 diabetes.

This condition refers to relative or absolute insulin deficiency. It is often aggravated by dehydration, hyperglycemia, and derangements in intermediary metabolism as a result of acidosis. Some of the main causes of this condition are disruption in insulin treatment, new onset of diabetes and underlying infections.

Clinically, it can be defined as an acute state of severe and uncontrolled diabetes associated with ketoacidosis often requiring emergency treatment with intravenous fluids and insulin.

Diabetic ketoacidosis refers to an often serious complication common with patients of diabetes. The complication makes the blood have high level of acids. The acid is referred to as ketones.

Diabetic ketoacidosis arises when the body is not able to produce enough insulin. Insulin usually plays a very important role in helping sugar to get into the cells. The sugar is the main source of energy for the muscles and other tissues to enter the cells. When the insulin is not enough, the body starts to break down fat as if struggles to replace sugar as fuel. As this process goes on, there will be a build-up of the toxic acids (ketones). As this goes on, diabetic ketoacidosis or DKA will develop.

People who have diabetes need to understand the symptoms of DKA so as to seek emergency care as soon as these signs are seen.

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2. Umpierrez GE, Jones S, Smiley D, et al. Insulin analogs versus human insulin in the treatment of patients with diabetic ketoacidosis: a randomized controlled trial. Diabetes Care. Jul 2009;32(7):1164-9. 
3. Herrington WG, Nye HJ, Hammersley MS, Watkinson PJ. Are arterial and venous samples clinically equivalent for the estimation of pH, serum bicarbonate and potassium concentration in critically ill patients?. Diabet Med. Jan 2012;29(1):32-5.
4. Mrozik LT, Yung M. Hyperchloraemic metabolic acidosis slows recovery in children with diabetic ketoacidosis: a retrospective audit. Aust Crit Care. Jun 26 2009
5. Bowden SA, Duck MM, Hoffman RP. Young children (< 5 yr) and adolescents (>12 yr) with type 1 diabetes mellitus have low rate of partial remission: diabetic ketoacidosis is an important risk factor. Pediatr Diabetes. Jun 2008;9(3 Pt 1):197-201. 
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10. Arieff AI, Carroll HJ. Nonketotic hyperosmolar coma with hyperglycemia: clinical features, pathophysiology, renal function, acid-base balance, plasma-cerebrospinal fluid equilibria and the effects of therapy in 37 cases. Medicine (Baltimore) 1972; 51:73.