Diabetic ketoacidosis (DKA) is a serious, life-threatening medical emergency that most often affects people with type 1 diabetes. It happens when the body does not have enough insulin to use glucose for energy. Without insulin, the body breaks down fat instead — and that process produces toxic substances called ketones. If left untreated, DKA can lead to a coma or death. This article explains the warning signs, causes, diagnosis, and treatment of DKA so you can act quickly if it ever happens to you or someone you love.
What Is Diabetic Ketoacidosis?
Diabetic ketoacidosis occurs when blood sugar rises to dangerously high levels and ketones build up in the blood. This creates a state of severe metabolic imbalance called metabolic acidosis. The body’s normal chemistry is disrupted in a way that affects the brain, muscles, and liver.
Normally, your body uses glucose as its main source of energy. However, glucose can only enter your cells with the help of insulin. When insulin levels are too low, your cells are starved of energy. As a result, your body turns to fat for fuel instead.
Breaking down fat produces ketones. In small amounts, ketones are harmless. However, when they build up rapidly, they make your blood dangerously acidic. This is what defines diabetic ketoacidosis.
DKA is most common in people with type 1 diabetes, but it can also occur in some people with type 2 diabetes. According to Health Canada, diabetes affects millions of Canadians, making awareness of complications like DKA critically important.
Common Causes of Diabetic Ketoacidosis
DKA does not happen randomly. There are clear triggers that can bring it on. Understanding these causes can help you avoid a dangerous episode.
The most common causes include:
Not enough insulin: Missing insulin doses or taking too little insulin is the leading cause of DKA. This may happen by accident or due to a problem with an insulin pump.
Illness or infection: A cold, flu, urinary tract infection, or other illness can raise stress hormones. These hormones work against insulin and can trigger DKA even if you take your medication as usual.
Undiagnosed type 1 diabetes: Sometimes DKA is the first sign that a person has diabetes. This is especially true in children and young adults.
Physical or emotional stress: Major stress — including surgery or a serious injury — can disrupt the body’s hormonal balance and raise blood sugar quickly.
Severe dehydration: Not drinking enough fluids can worsen high blood sugar and speed up the development of DKA.
Hormonal imbalances: Excess levels of glucagon, cortisol, and adrenaline can all work against insulin and contribute to DKA.
In many cases, a combination of these factors triggers the episode. For example, a person with type 1 diabetes who gets the flu and forgets an insulin dose is at very high risk.
Recognising the Symptoms of Diabetic Ketoacidosis
DKA symptoms can develop quickly — sometimes within 24 hours. Recognising them early can save a life. The symptoms are directly linked to high blood sugar and the build-up of ketones in the blood.
Early Warning Signs
The early signs of diabetic ketoacidosis are often mistaken for a regular illness. Watch for these symptoms:
Extreme thirst and frequent urination
High blood sugar levels (hyperglycaemia)
Fatigue and weakness — difficulty waking up or staying alert
Blurred vision
Flushed, warm, and dry skin
Loss of appetite, nausea, and vomiting
Stomach pain
In children, early signs can be more subtle. Parents should watch for loss of interest in normal activities, poor concentration, and unusual tiredness.
Advanced Symptoms
If DKA is not treated promptly, symptoms become much more serious. These include:
Fruity or acetone-like breath: The breath may smell sweet, like nail polish remover or unripe apples. This is caused by ketones escaping through the lungs.
Kussmaul breathing: This is a deep, rapid, laboured breathing pattern. The body tries to get rid of acid by breathing it out.
Mental confusion: The person may seem disoriented, agitated, or unable to think clearly.
Lethargy: Extreme tiredness and drowsiness that gets steadily worse.
Brain swelling (cerebral oedema): In severe cases, fluid can build up in the brain. This is a medical emergency, especially in children.
Loss of consciousness and coma: Without immediate treatment, DKA can cause the person to lose consciousness.
Furthermore, the combination of vomiting and high blood sugar can lead to severe dehydration very quickly. Do not wait to seek help if these symptoms appear. Call 911 or go to your nearest emergency department immediately.
How Is Diabetic Ketoacidosis Diagnosed?
Doctors diagnose DKA using a combination of physical assessment and laboratory tests. A thorough medical history from the patient or their family is the first step. Doctors will ask about diabetes history, insulin use, recent illness, and current symptoms.
Blood and Urine Tests
Laboratory tests confirm the diagnosis. The key markers doctors look for include:
High blood glucose: Blood sugar is typically very elevated — often above 14 mmol/L in Canada (compared to a normal fasting level of 4–7 mmol/L).
Ketones in the blood and urine: Elevated ketone levels confirm the body is burning fat instead of glucose.
Metabolic acidosis: The blood becomes more acidic than normal. Doctors measure bicarbonate (HCO3), which is low in DKA.
Electrolyte imbalances: Levels of sodium, potassium, and chloride in the blood are often disrupted.
Elevated creatinine: This can indicate strain on the kidneys caused by dehydration.
These tests help doctors assess how severe the DKA episode is and guide the right course of treatment. According to the Mayo Clinic’s overview of diabetic ketoacidosis, prompt testing is critical to avoiding life-threatening complications.
Treatment for Diabetic Ketoacidosis
Diabetic ketoacidosis must be treated in a hospital, often in an intensive care unit (ICU). This is not a condition that can be managed at home. Treatment focuses on three main goals: replacing lost fluids, restoring insulin levels, and correcting the chemical imbalance in the blood.
Intravenous Fluids
The first step in treatment is rehydration. Doctors give fluids directly into the vein (intravenously). This helps replace fluids lost through frequent urination and vomiting. It also helps dilute the excess sugar in the blood.
Insulin Therapy
Insulin is given intravenously to bring blood sugar back to a safe level. This also stops the breakdown of fat and the production of ketones. Doctors carefully monitor blood sugar throughout this process to avoid lowering it too quickly.
Electrolyte Replacement
DKA disrupts important minerals in the blood, especially potassium. Doctors replace these electrolytes intravenously. Keeping electrolytes balanced is essential for the heart, muscles, and nerves to function properly.
In many cases, it takes several days of hospital treatment before blood sugar normalises and the metabolic acidosis fully resolves. Recovery depends on how quickly treatment began and how severe the episode was.
For more information on managing diabetes and preventing complications, visit the Healthline guide on diabetic ketoacidosis.
Risk Factors for Diabetic Ketoacidosis
Not everyone with diabetes faces the same level of risk. However, certain people are more vulnerable to developing DKA.
The highest-risk group is people with type 1 diabetes — particularly those who:
Regularly miss or forget insulin doses
Use an insulin pump that malfunctions or gets blocked
Are newly diagnosed and not yet stable on a treatment plan
Have frequent infections or other illnesses
Experience high levels of emotional or physical stress
Children and teenagers with type 1 diabetes are especially at risk. Managing insulin needs during growth spurts, illness, and emotional stress can be challenging. Parents and caregivers should be well-informed about the warning signs.
People with type 2 diabetes can also develop DKA, though it is less common. Factors like severe infection, certain medications, and extreme dehydration can trigger it in this group as well.
Preventing Diabetic Ketoacidosis
The good news is that most episodes of DKA are preventable. With the right habits and a solid management plan, people with diabetes can significantly reduce their risk.
Here are the most effective prevention strategies:
Take insulin as prescribed: Never skip or reduce your insulin dose without first speaking with your doctor or diabetes care team.
Monitor blood sugar regularly: Check your blood glucose levels as recommended — especially during illness or stress.
Test for ketones: If your blood sugar is consistently above 14 mmol/L, test your urine or blood for ketones. Home ketone testing kits are available at most Canadian pharmacies.
Have a sick-day plan: Work with your healthcare provider to create a clear plan for managing diabetes during illness. Do not stop taking insulin even if you are not eating.
Stay hydrated: Drink plenty of water, especially when you are sick or physically active.
Attend regular check-ups: Regular visits to your family doctor or endocrinologist help catch problems before they become emergencies.
In Canada, most provincial health plans cover diabetes monitoring supplies and medications. Check with your provincial health programme or a pharmacist to understand what is covered in your province.
When to See a Doctor
If you or someone you know has diabetes and is showing signs of DKA, do not wait. Call 911 or go to your nearest emergency department immediately. DKA is a medical emergency — every minute matters.
However, prevention starts long before a crisis. If you have diabetes, make sure you have a regular family doctor or diabetes specialist. If you do not have a family doctor, a walk-in clinic can help you access blood sugar monitoring, insulin prescriptions, and referrals to an endocrinologist.
Talk to your doctor if you notice your blood sugar is frequently high, if you are unsure how to adjust your insulin during illness, or if you have had a previous DKA episode. Your provincial health plan may also cover access to a diabetes education programme — these programmes can teach you how to manage your condition safely at home.
Always consult your doctor or a qualified healthcare provider before making any changes to your diabetes treatment plan. This article is for general information only and is not a substitute for professional medical advice.
Frequently Asked Questions About Diabetic Ketoacidosis
What triggers diabetic ketoacidosis?
Diabetic ketoacidosis is most often triggered by not taking enough insulin, a missed dose, or an illness like the flu or a urinary tract infection. Physical or emotional stress and severe dehydration can also bring on a DKA episode. In some cases, DKA is the first sign that a person has undiagnosed type 1 diabetes.
Can you have diabetic ketoacidosis with normal blood sugar?
In most cases, diabetic ketoacidosis is associated with very high blood sugar levels. However, a rare form called euglycaemic DKA can occur with near-normal blood sugar — most often in people taking a class of diabetes medication called SGLT2 inhibitors. This is why checking for ketones matters, not just blood glucose levels.
How long does it take to recover from diabetic ketoacidosis?
Recovery from diabetic ketoacidosis typically takes one to three days in hospital with proper treatment. Doctors will monitor blood sugar, ketone levels, and electrolytes until everything returns to a safe range. Full recovery at home may take a few additional days, depending on how severe the episode was.
Is diabetic ketoacidosis only a type 1 diabetes problem?
Diabetic ketoacidosis most commonly affects people with type 1 diabetes, but it can also occur in people with type 2 diabetes under certain conditions. Severe infection, extreme dehydration, and some medications can trigger DKA in type 2 diabetes as well. Anyone with diabetes should know the warning signs regardless of their type.
What does diabetic ketoacidosis breath smell like?
One of the distinctive signs of diabetic ketoacidosis is a fruity or acetone-like smell on the breath. It is often compared to nail polish remover or unripe apples. This happens because ketones — the toxic byproducts produced when the body burns fat — are released through the lungs when you breathe out.
