27th May 2025

Precipitating factors and clinical presentation

Causes of DKA include the 7 I’s of DKA:

• Infection 
• Insulin missed 
• Ischaemia – acute coronary syndrome, critical limb ischaemia or ischaemic bowel  
• Initial presentation – new onset of diabetes especially in young children 
• Intoxication – cocaine, cannabis and acute intoxication with alcohol 
• Impregnation – pregnancy increases metabolic demands 
• Iatrogenic – drugs (corticosteroids, thiazides, sodium-glucose co-transporter 2 (SGLT2) inhibitors, symphathomimetics, second generation antipsychotics, immune checkpoint inhibitors)

Clinical Presentation

• Nausea and vomiting 
• Abdominal pain 
• Polydipsia, polyuria and dehydration 
• Kussmaul respiration (deep hyperventilation)
• Ketotic breath (acetone or ‘pear drops’ smell)
• Reduced consciousness 
• Hypothermia

Investigations

All patients with suspected DKA should have the following investigations:

• Venous Blood Gas: pH <7.0 indicates severe DKA, hyperkalaemia is common
• Blood ketones or urinary ketones: ketonaemia is blood ketones >3.0 mmol/L
• Blood glucose: hyperglycaemia is >11mmol/L
• Bloods including:
  • Full Blood Count: leukocytosis is common, consider infection if markedly raised white cell count  
  • Urea and Electrolytes: hypernatraemia is common indicating dehydration, hyperkalaemia is common but hypokalaemia on arrival is an indicator of severe DKA as total body potassium is low

Other investigations to be considered include: 

• Urinalysis: ketonuria 2+ on standard urine sticks, may be positive for glucose, leukocytes and nitrites in the presence of urinary tract infection 
• ECG: looking for myocardial ischaemia 
• Amylase and Lipase 
• Cardiac enzymes: raised troponin I if myocardial infarction is suspected  
• Creatinine kinase: if rhabdomyolysis is suspected  
• Chest x-ray: look for consolidation in pneumonia and signs of pulmonary oedema if the patient is desaturating after fluid resuscitation
• Liver function tests: screen for an underlying hepatic cause of DKA 
• Blood, urine and sputum cultures: order if there are signs of infection 
• Pregnancy test: in women of child bearing age, pregnancy increases metabolic demands and can cause DKA in diabetic patients