🚨 Men's Health

Diabetic Ketoacidosis (DKA) — Recognising a Crisis

DKA is a life-threatening emergency — what causes it and what to do

Diabetic ketoacidosis (DKA) is a life-threatening metabolic emergency that occurs when the body produces high levels of blood acids called ketones — primarily in people with type 1 diabetes, but increasingly seen in type 2 diabetes, particularly under severe illness or insulin deficiency. It results from a severe lack of insulin, causing the body to break down fat as fuel, producing ketones that acidify the blood. In Nigeria, DKA is frequently precipitated by infections (malaria, typhoid, pneumonia), missed insulin doses (due to cost or supply problems), and newly diagnosed type 1 diabetes. It is the leading cause of hospitalisation and death in young type 1 diabetics.

Signs and Symptoms

✓ Early: excessive thirst (polydipsia), frequent urination (polyuria), fatigue, nausea

✓ Progressive: vomiting, abdominal pain (may mimic acute abdomen), loss of appetite

✓ Classic signs: Kussmaul breathing (deep, rapid, laboured breathing — body trying to expel CO2 to compensate for acidosis), fruity/pear-drop smell to breath (from ketones)

✓ Advanced: confusion, drowsiness, eventually coma

✓ Blood glucose: typically > 13.9 mmol/L (250 mg/dL) but 'euglycaemic DKA' exists (normal glucose) with SGLT-2 inhibitors

✓ Ketones: positive on urine dipstick (3+ ketonuria) or blood ketones > 3 mmol/L

Risk Factors

Type 1 diabetes: most common affected group — complete insulin deficiency
Missed or insufficient insulin: most common precipitant in Nigeria — insulin costs, supply disruptions, needle unavailability
Infections: any significant infection increases insulin requirements dramatically. Malaria, typhoid, UTI, pneumonia are frequent Nigerian precipitants
Newly diagnosed type 1 diabetes: DKA is the presenting event in 30% of new type 1 diagnoses
Sick day rules not followed: illness → vomiting → unable to eat → patient stops insulin → DKA
SGLT-2 inhibitors (empagliflozin, dapagliflozin): can cause euglycaemic DKA — ketones develop even with near-normal glucose

When to Seek Help

Diabetic vomiting and unable to keep fluids downEmergency — dehydration + inability to take oral medications = hospital admission

Blood or urine ketones detected with high blood sugarDKA developing — go to hospital immediately

Diabetic who is confused, drowsy, or breathing rapidly and deeplyAdvanced DKA or hyperosmolar state — resuscitation emergency

Type 1 diabetic with any significant infection and blood sugar > 14 mmol/LHigher insulin requirements during illness — close monitoring and dose adjustment needed

Newly diagnosed young person with excessive thirst, polyuria, and weight lossPossible new type 1 diabetes — risk of DKA at presentation. Urgent blood glucose test

Tests & Diagnosis

🧪 Blood glucose

Usually > 13.9 mmol/L in DKA. Finger-prick glucose at bedside

🧪 Urine ketones (dipstick)

3+ ketonuria supports DKA diagnosis. Widely available at Nigerian hospitals

🧪 Blood ketones (beta-hydroxybutyrate)

More accurate than urine ketones. > 3.0 mmol/L = DKA. Available at some Nigerian laboratories

🧪 Venous blood gas (VBG)

pH < 7.3 = acidosis. Bicarbonate < 15 mmol/L. Anion gap > 16. Confirms DKA and severity

🧪 Electrolytes (particularly potassium)

Total body potassium is depleted in DKA despite often normal serum K+. Dangerous hypokalaemia develops as insulin drives K+ into cells during treatment — must be monitored hourly

🧪 Full blood count and infection screen

Identify precipitating infection — malaria RDT, blood culture, urine culture, chest X-ray

Treatment Options

IV fluid resuscitation

0.9% normal saline: 1 litre over 1 hour initially, then 1 litre over 2 hours, then 1 litre over 4 hours. Corrects dehydration and reduces blood glucose. Critical first step

IV insulin infusion

Regular (soluble) insulin at 0.1 units/kg/hour IV. Reduces blood glucose by approximately 3–5 mmol/L/hour. Do NOT give subcutaneous insulin initially — absorption unreliable in dehydrated patient

Potassium replacement

Add 20–40 mmol KCl to each litre of IV fluid once potassium < 5.5 mmol/L. Monitor potassium hourly — failure to replace causes fatal cardiac arrhythmia

Treat the precipitant

Antibiotics for infection. Artemether-lumefantrine if malaria confirmed. Insulin dose increase during illness

Transition to subcutaneous insulin

When blood glucose < 14 mmol/L, switch IV fluids to 10% dextrose + 0.45% saline to prevent hypoglycaemia while continuing insulin. Transition to subcutaneous insulin once eating and pH normalised

Sick day rules education (at discharge)

Never stop insulin during illness. If vomiting — call for help. Check blood glucose every 2–4 hours when unwell. Test ketones if glucose > 13 mmol/L

Frequently Asked Questions

Can DKA happen if I take my insulin?

Yes, if insulin dose is insufficient for the situation. During infection, surgery, or significant illness, insulin requirements increase 2–3 fold. Taking your usual dose may be insufficient. This is why 'sick day rules' — increasing insulin dose monitoring during illness — are essential knowledge for every insulin-dependent diabetic.

Is DKA only for type 1 diabetes?

DKA occurs predominantly in type 1 diabetes (complete insulin deficiency) but can also occur in type 2 diabetes during severe illness, with SGLT-2 inhibitors, or when insulin production fails significantly. A new phenomenon called ketosis-prone type 2 diabetes (which is actually more common in people of African descent, including Nigerians) can present with DKA despite being type 2.

My child has been vomiting and has high blood sugar — what do I do?

Go to hospital immediately. Vomiting + high blood sugar + type 1 diabetes = presumed DKA until proved otherwise. Do not wait to see if it improves. Every hour of delay worsens the acidosis. IV fluids and insulin need to be started as soon as possible.

Can DKA be prevented?

Most cases are preventable. The keys are: (1) Never stop insulin without medical advice, even when unable to eat. (2) Increase blood glucose monitoring during illness. (3) Seek medical help early when unwell rather than waiting. (4) Address the cause of DKA (usually infection) promptly. (5) Ensure consistent insulin supply — medication stockouts are a preventable cause of DKA deaths in Nigeria.