A patient with insufficient insulin (or resistance to the effect of insulin) may not be able to transport enough glucose into cells to meet metabolic needs despite hyperglycemia in the peripheral blood. The cell may shift to lipid oxidation with metabolic acidosis and release of ketone bodies. Prompt recognition and management are important to prevent serious sequelae.

Patient selection: diabetes


Early symptoms may include:

(1) malaise

(2) facial flushing

(3) anorexia

(4) thirst

(5) drowsiness

(6) polyuria

(7) fatigue, lethargy or weakness


If uncorrected, the symptoms may progress with:

(1) rapid, deep breathing (Kussmaul breathing)

(2) tachycardia

(3) nausea and vomiting

(4) dehydration secondary to osmotic diuresis with oliguria

(5) altered mental status when serum osmolality > 320 mOsm/kg, which can progress to coma

(6) a fruity odor on the breath or an odor similar to nail polish remover (acetone)

(7) findings associated with the trigger for the ketoacidosis

(8) variable mild abdominal pain


Laboratory testing may show:

(1) hyperglycemia

(2) large amounts of glucose and acetone in the urine

(3) metabolic acidosis

(4) sodium and potassium depletion

(5) ketone bodies (acetoacetic acid and beta-hydroxybutyrate) in blood and urine

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