Ketoacidosis is a metabolic emergency in which a severe lack of insulin drives the body to break down fat for energy, producing ketone bodies faster than they can be cleared. The accumulation of these acidic ketones lowers blood pH, and the accompanying hyperglycaemia causes osmotic diuresis, dehydration and electrolyte loss.
Diabetic ketoacidosis (DKA) is the most common form and is classically associated with type 1 diabetes, though it can occur in type 2. It may be the first presentation of diabetes, or it may develop in someone already diagnosed. Alcoholic and starvation ketoacidosis are related but distinct entities with different triggers.
All three are needed. Euglycaemic DKA, where glucose is near normal, is an important exception and is recognised particularly in people taking SGLT2 inhibitors, in pregnancy and where insulin has been partially continued.
Patients typically report thirst, frequent urination, weight loss, nausea and vomiting and abdominal pain. Examination may show dehydration, deep sighing Kussmaul respiration, a ketotic smell on the breath and reduced consciousness. Common precipitants are infection, missed or reduced insulin doses, insulin pump failure, myocardial infarction and new onset diabetes.
Treatment follows a structured pathway: intravenous fluid resuscitation to correct dehydration, a fixed rate intravenous insulin infusion to switch off ketogenesis, and careful potassium replacement, since insulin drives potassium into cells and profound hypokalaemia is a leading cause of death in DKA. Long-acting background insulin is continued alongside the infusion. Glucose and ketones are monitored hourly, the precipitating cause is treated, and the patient is not switched back to subcutaneous insulin until the ketoacidosis itself has resolved.
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