Last Modified: 9:18am 23/04/2021

How to Recognise

For young people under the age of 18 years use the BSPED DKA guidelines which can be found at

It is a medical emergency in diabetes (usually type 1 diabetes, but can occur in type 2 diabetes) that can develop over hours to days

Diagnostic criteria, ALL 3 of:

  • Blood glucose > 11mmol/L
  • HCO3 <15 mmol/L &/or venous pH <7.3
  • Ketonaemia > 3mmol/L or ketonuria (> ++ on urine ketostix)

(Joint British Diabetes Societies 2010)

What are the signs of DKA?

  • High BG levels
  • Ketones (in blood and urine)
  • Nausea, vomiting, and abdominal pain (cramps)
  • Confusion
  • Tired, sluggish, or weak
  • Flushed, hot, dry skin
  • Blurred vision
  • Rapid, deep breathing and shortness of breath
  • Excessive thirst and frequent urination
  • Fruity scented breath
  • Unconsciousness

Check your patients blood sugar level if they have symptoms of DKA.

If their blood sugar level is 11mmol/L or above and they have any of the above symptoms check their ketone level.

If you do a blood ketone test:

  • lower than 0.6mmol/L is a normal reading
  • 0.6 to 1.5mmol/L means a slight increased risk of DKA and you should test again in 2 hours
  • 1.6 to 2.9mmol/L means  an increased risk of DKA and should escalate to the medical team.
  • 3mmol/L or above means you have a very high risk of DKA and should get escalate immediately for assessment by the medical team and a venous blood gas.

The presence of one or more of the following may indicate severe DKA.

If the patient exhibits any of these signs below they should be reviewed by a consultant physician and considered for referral to the Level 1 pathway and ICU review (JBDS Guidelines 2013).

• Blood ketones over 6mmol/L

• Bicarbonate level below 5mmol/L

• Venous/arterial pH below 7.0

• Hypokalaemia on admission (under 3.5mmol/L)

• GCS less than 12 or abnormal AVPU scale

• Oxygen saturation below 92% on air (assuming normal baseline respiratory function)

• Systolic BP below 90mmHg

• Pulse over 100 or below 60bpm

• Anion gap above 16 [Anion Gap = (Na+ + K+) (Cl-+ HCO3-) ]