Diabetic Ketoacidosis: Warning Signs and Hospital Treatment

Diabetic ketoacidosis, or DKA, is not just a complication-it’s a medical emergency that can kill within hours if ignored. It doesn’t wait for a doctor’s appointment. It strikes suddenly, often in people who thought they were managing their diabetes fine. And too many people don’t recognize the signs until it’s too late. If you or someone you care about has type 1 diabetes-or even type 2 with little to no insulin production-you need to know what DKA looks like, how fast it moves, and what happens when you get to the hospital.

What DKA Actually Is

DKA happens when your body runs out of insulin. Without insulin, glucose can’t get into your cells for energy. So your body starts breaking down fat instead. That process produces ketones-acidic chemicals that build up in your blood. When ketones pile up, your blood turns acidic. That’s what makes DKA dangerous. Blood sugar is usually above 250 mg/dL, but not always. Some people develop euglycemic DKA, where blood sugar is normal or only slightly high, but ketones are still dangerously high. This is especially common in people taking SGLT2 inhibitors or during illness.

DKA mostly affects people with type 1 diabetes-about 80% of cases. But it can also happen in type 2 diabetes if insulin production drops sharply, like during severe infection, trauma, or if someone stops taking insulin because they can’t afford it. In kids, DKA is often the first sign that they have diabetes. About 30% of pediatric DKA cases are the first time the disease is ever diagnosed.

Early Warning Signs You Can’t Ignore

The first signs come on fast-usually within 4 to 12 hours. You might think it’s just the flu, a stomach bug, or dehydration. But these aren’t normal symptoms. They’re your body screaming for help.

• Extreme thirst-drinking 4 to 6 liters of water a day and still not satisfied.
• Frequent urination-going every hour, even at night. You might soak through sheets.
• Very dry mouth-so dry it hurts to swallow. This happens in nearly 9 out of 10 people with DKA.
• Blood sugar over 250 mg/dL-if you’re checking, this is your first red flag.

At this stage, you can still act. Check your ketones. If you have a blood ketone meter and it reads above 3 mmol/L, you need to go to the hospital-now. Don’t wait. Don’t call your doctor and wait for an appointment. Don’t try to "power through it."

When Symptoms Get Critical

If you don’t act in the next 12 to 24 hours, things spiral. The body’s acid levels rise. Your breathing changes. Your brain starts to fog.

• Nausea and vomiting-75% of people with DKA can’t keep anything down. Vomiting isn’t just uncomfortable-it’s a sign your body is shutting down.
• Abdominal pain-it can feel like appendicitis or food poisoning. That’s why 18% of adult DKA cases are misdiagnosed as gastroenteritis in emergency rooms.
• Extreme fatigue and weakness-you can’t stand up. You can’t walk to the bathroom. Your grip strength drops by 30-40%.
• Deep, rapid breathing-this is called Kussmaul respirations. It’s your body trying to blow off acid by breathing faster. It sounds like gasping. You might not even notice it’s happening until someone else points it out.
• Fruity-smelling breath-it smells like nail polish remover or overripe apples. That’s acetone, one of the ketones. Clinicians can smell it before they even test.
• Confusion or disorientation-if you’re having trouble thinking clearly, remembering names, or following simple instructions, you’re in danger.
• Loss of consciousness-this is a last resort. If someone passes out, call 999 immediately.

These aren’t "maybe" signs. They’re hard indicators that your blood is too acidic. If you have two or more of these symptoms and your blood sugar is over 250 mg/dL, go to the ER. No excuses.

What Happens in the Hospital

Once you’re admitted, the hospital team doesn’t waste time. They follow strict, evidence-based protocols to bring you back from the edge.

First: Fluids. You’re dehydrated-badly. The first hour is all about replacing lost fluid. You’ll get 15-20 mL per kilogram of body weight of saline solution-about 1 to 1.5 liters for most adults. This helps your kidneys flush out ketones and restores blood pressure.

Second: Insulin. You’ll get a small IV bolus of insulin, then a continuous drip. The goal isn’t to drop blood sugar fast-it’s to drop it steadily. Too fast, and you risk brain swelling, especially in children. The target is 50-75 mg/dL per hour. That’s slow enough to be safe, fast enough to save your life.

Third: Electrolytes. Your potassium is probably low-even if the blood test says it’s normal. Insulin pushes potassium into cells, and you’ve lost a lot through urine. You’ll get potassium IV, usually 20-30 mEq per hour, to keep your heart beating right. Sodium and chloride are also monitored closely.

Fourth: Monitoring. Blood sugar is checked every hour. Ketones are checked every 2-4 hours. Electrolytes every 2-6 hours. You’re not just getting treatment-you’re being watched like a hawk. The moment your blood pH climbs above 7.3 and ketones drop below 0.6 mmol/L, you’re on the road to recovery.

And here’s something you won’t hear often: you don’t need bicarbonate. Most hospitals still give it out of habit, but it’s not recommended unless your pH is below 6.9. That’s rare. And giving bicarbonate too early can make things worse.

How Long Do You Stay?

Most people stay 2.5 to 4 days. But your length of stay depends on how bad it was when you arrived. If your blood pH was 7.0 or lower, you’ll likely stay longer-around 3.8 days on average. If it was 7.1 or higher, you might be out in 2.1 days.

Discharge isn’t just about numbers. You need to be eating, drinking, and able to manage your insulin again. You’ll get a full education session before you leave. If you’re on an insulin pump, you’ll be told to switch to injections until you’re fully recovered. Infusion set failures cause 35% of pump-related DKA cases.

What Causes DKA? And Why It Keeps Happening

There are three big triggers:

• Infections-pneumonia, urinary tract infections, flu. They spike stress hormones, which block insulin.
• Missing insulin-whether it’s because you forgot, you ran out, or you couldn’t afford it. In the U.S., the average monthly insulin cost is $374. Some people ration. That’s how DKA starts.
• New-onset diabetes-especially in kids. Many are diagnosed in the ER because no one knew they had diabetes until they collapsed.

And here’s the ugly truth: DKA rates are rising in the U.S. by over 5% each year. Uninsured patients are 3.2 times more likely to get it. That’s not about medical failure-it’s about economic failure.

How to Prevent It

DKA isn’t inevitable. You can reduce your risk dramatically.

• Check ketones when blood sugar is over 240 mg/dL. Use a blood ketone meter if you can. Urine strips are outdated-they’re slow and inaccurate.
• Never skip insulin, even if you’re not eating. During illness, you need more insulin, not less.
• Use a CGM. People with continuous glucose monitors (like Dexcom G7) reduce DKA by 76%. High glucose and ketone alerts give you hours to act before you’re in crisis.
• Know your triggers. If you get sick, check ketones every 4 hours. Call your endocrinologist before you wait for an ER.
• Have a sick-day plan. Write it down. Include insulin dosing adjustments, when to call for help, and emergency contacts.

The FDA just approved the first DKA prediction algorithm-DiaMonTech’s DKA Risk Score. It uses CGM data to predict DKA 12 hours before it happens. It’s not everywhere yet, but it’s coming. That’s the future: prevention, not just treatment.

What Happens If You Wait Too Long

Every hour you delay fluids and insulin, your risk of death goes up by 15%. That’s not a guess. That’s from Dr. Irl Hirsch at the University of Washington, cited in Diabetes Care. And in children, cerebral edema-the brain swelling that comes from too-fast fluid correction-is the leading cause of death. It happens in 0.5-1% of cases, but 21-24% of those children die.

And if you’re misdiagnosed? That’s a nightmare. You’re sent home with anti-nausea meds. You keep vomiting. You get more dehydrated. You slip into a coma. By the time you’re back in the ER, you’re fighting for your life.

Final Word: Don’t Wait for a Crisis

DKA doesn’t care if you’re busy, scared, broke, or tired. It doesn’t wait for insurance approval. It doesn’t care if you’ve been managing diabetes for years. One missed dose, one infection, one ignored symptom-and you’re in danger. The tools to prevent it exist: CGMs, ketone meters, sick-day plans, and education. Use them. Talk to your care team. Know your numbers. And if you see those signs-thirst, vomiting, fruity breath, confusion-don’t call your doctor. Go to the hospital. Your life depends on it.