Diabetic Ketoacidosis Calculator

Created by Aleksandra Zając, MD
Reviewed by Dominik Czernia, PhD candidate
Based on research by
Dyanne P. Westerberg Diabetic Ketoacidosis: Evaluation and Treatment Am Fam Physician (01/03/2013)See 1 more source
Stamatis P Efstathiou 1, Aphrodite G Tsiakou, Dimitrios I Tsioulos, Ioannis D Zacharos, Athanasios G Mitromaras, Stylianos E Mastorantonakis, Themistoklis N Panagiotou, Theodore D Mountokalakis A mortality prediction model in diabetic ketoacidosis https://pubmed.ncbi.nlm.nih.gov (2002 Nov)
Last updated: May 23, 2022

If you're willing to know more about one of the acute complications of diabetes, the diabetic ketoacidosis calculator article is the right place. You will finally solve the riddle of what is Kussmaul breathing, why is bicarbonate low in diabetic ketoacidosis (DKA), and how does diabetes cause acidosis exactly. Have you ever wondered, can non-diabetics get ketoacidosis as well? The diabetic ketoacidosis calculator will give you all the answers!

We try our best to make our Omni Calculators as precise and reliable as possible. However, this tool can never replace a professional doctor's assessment. If any health condition bothers you, consult a physician.

What is diabetic ketoacidosis?

Diabetic ketoacidosis definition (DKA) says it's a condition, when three states:

  • HyperglycemiaSerum glucose >250 mg/dL, informally high blood sugar;
  • Acidosis – Arterial blood pH <7.3 and bicarbonate <15 mEq/L; and
  • Ketosis – Presence of ketones in the blood and/or urine).

...combine together into a syndrome.

It is one of the acute complications of diabetes and mainly occurs in type 1 diabetes (DM1). Often, it's even the very first presentation of type 1 diabetes.

The cause of diabetic ketoacidosis is not enough insulin to meet the body's needs. When insulin is not present, the glucose cannot enter the cells and provide energy (read more about insulin function in the HOMA-IR calculator).

Insulin deficiency and hyperglycemia cause many metabolism disorders, affecting acid-base balance and electrolyte levels in the body. The condition develops quickly (hours to days), and if not medically assisted, can be life-threatening.

How does diabetes cause acidosis? What is Kussmaul breathing?

The main underlying problem of diabetic ketoacidosis is a lack of insulin:

  • Absolute (when the insulin is absent); or
  • Relative (when body cells don't react to the insulin that is present).

Acidosis can also come about when the need for glucose and insulin is suddenly greater – during an infection, acute cardiovascular disease, or alcohol overuse.

Without insulin, glucose particles (the primary energy source coming from carbohydrates) that circulate in the body cannot enter the cells. So, despite the high blood sugar level, tissues cannot use it. The cells are starving. The body is alarmed and tries to get some energy from other sources:

  • Several hormones – e.g., epinephrine, cortisol, glucagon – is released, and those hormones induce even higher blood sugar level;
  • The liver starts to break the glycogen down, which produces more glucose; and
  • The liver starts to break down other possible sources of glucose, such as proteins and fats.

As we can see, the major effect of this stage is a further increase in the blood glucose level when the cells are still starving.

When the blood sugar level hits the renal threshold level, the kidneys cannot reabsorb it anymore, and glucose appears in the urine. Glucose drags water and electrolytes (K+, Na+, Cl-) with it into the urine. This phenomenon is responsible for excessive urination, dehydration, and thirst.

The breakdown of lipids (fats) produces ketones. One of them, acetone, is highly volatile and gives that specific sweet breath of a patient with ketoacidosis. Ketones are acidic, and when present in the organism in a large amount, they change the arterial blood pH to an acidic one (below 7.35).

Now, we come to the point where we explain what Kussmaul breathing is. It happens when the lungs, trying to switch the acid-base balance into more alkaline, get rid of CO2, presenting this symptom. Another compensation mechanism is pushing H+ ions into cells with an exchange for K+. This results in hyperkalemia – a complication that, if untreated, is highly dangerous as it can affect the heart work.

Diabetic ketoacidosis diagnostic criteria

Only four criteria are needed to diagnose DKA. Those are:

  • Blood glucose level over 250 mg/dL (13.8 mmol/L);
  • Serum bicarbonate level less than 18 mEq/L (18 mmol/L);
  • Blood pH less than 7.3; and
  • Elevated serum ketone level.

However, there are more parameters worth assessing in the patient. Here is the list of the criteria, differentiated by the severity of the underlying disorder.

Criteria

Mild DKA

Moderate DKA

Severe DKA

Serum glucose

>250 mg/dL (13.8 mmol/L)

>250 mg/dL (13.8 mmol/L)

>250 mg/dL (13.8 mmol/L)

Anion gap

up to 12 mEq/L

>12 mEq/L

>12 mEq/L

Arterial pH

7.24-7.30

7.00-7.24

<7.00

Serum bicarbonate

15 to 18 mEq/L

10 to <15 mEq/L

<10 mEq/L

Serum ketone

Present

Present

Present

Urine ketone

Present

Present

Present

Mental status

Alert

Alert/drowsy

Stupor/coma

What is anion gap in diabetic ketoacidosis?

There are positive (cations) and negative (anions) ions in human blood. A total number of cations should equal the total number of ions. The overall electrical charge should be neutral. The anion gap is the difference between cations and ions measured in a blood test – because we cannot measure all ions possible. That anion gap shows what we're missing. Referring to DKA, an anion gap is needed to assess the severity of the disorder. The bigger the anion gap, the worse.

How to calculate anion gap in DKA? Use the following formula:

AG = [Na⁺] − ([Cl⁻] + [HCO₃⁻])

Or jump straight to our anion gap calculator.

What are the symptoms of diabetic ketoacidosis (DKA)?

DKA is always an acute condition. The accompanying symptoms are suggestive enough to make the patient seek medical help. So, what are the symptoms of diabetic ketoacidosis?

The symptoms encompass:

  • Fatigue, tiredness, & sleepiness;
  • Frequent urination;
  • Mouth dryness, excessive thirst;
  • Abdominal and chest pain; and
  • Nausea, vomiting.

What are the warning signs of diabetic ketoacidosis you might not notice immediately? The physician's examination will reveal:

  • High heart rate (tachycardia);
  • Low blood pressure (hypotension);
  • Rapid and deep breath – called Kussmaul breathing;
  • Dehydration signs (dry mucous membranes, dry skin, weight loss – without intention to do so);
  • Acetone, fruity mouth odor.

After a brief introduction to the topic and learning what diabetic ketoacidosis is and what causes diabetic ketoacidosis, let's quickly check how to use this DKA calculator.

DKA mortality

DKA is not a light disease that you can deal with at home. If you have diabetes and don't feel well, get to the hospital immediately. Better safe than sorry!

Diabetic ketoacidosis mortality rate varies from 0.2 to 2% of the patients that experience it. That's even 1 per every 50 persons. There are some signs of poor prognoses, such as comorbidities or significant insulin requirement. You can use the second mode of our calculator to calculate the mortality rate for the patients at least 24 hours after hospital admission.

Use of diabetic ketoacidosis calculator

Our diabetic ketoacidosis calculator is very easy to use:

  1. First, choose if you want to know the criteria of DKA or if you want to check the risk of death for the condition.
  2. If you've chosen diagnosis:
    • Check the conditions that apply to your patient.
    • You don't have to give us exact lab values. For simplicity and quickness of use, you only have to mark the range where the numbers are.
    • The results are right there, under the diabetic ketoacidosis calculator.
    • Although hyperglycemia is one of the American Diabetes Association (ADA) criteria, remember that euglycemic diabetic ketoacidosis is also possible in some instances. We explained this condition in the FAQ section of this DKA calculator.
  3. If you've chosen mortality:
    • Check the conditions that your patient meets.
    • Pay attention to the headlines, as they implicate which time after admission we refer to. We assess some parameters right away but wait 12 hours to evaluate the others.
    • When you're done, your result is ready at the bottom of the calculator.

Can non-diabetic get ketoacidosis?

Rarely but also people without a history of diabetes can experience ketoacidosis.

Literature gives us singular examples of patients who followed a strict low-carb diet and then were diagnosed in the ER with non-diabetic ketoacidosis. None of the patients had any history of diabetes. They usually got well pretty quickly and in 2-3 days were discharged from the hospital.

The risk of developing acidosis rises if you've been drinking too much alcohol and not eating right. That way, you can develop alcoholic ketoacidosis. It can happen even without underlying diabetes.

FAQ

What is euglycemic diabetic ketoacidosis?

Euglycemic diabetic ketoacidosis is a rare state when a patient experiences ketoacidosis without a high blood sugar level (hyperglycemia). The blood glucose level is normal.

It is often related to the use of new diabetes drugs called SGLT-2 inhibitors (e.g., dapagliflozin). The unusual nature of this condition makes the diagnosis difficult and delayed.

Why is potassium high in diabetic ketoacidosis?

In ketoacidosis, the blood pH is low (<7.3) and acidic because of the excessive ketones circulating in the bloodstream. The body tries to compensate for the acidic environment through two main mechanisms:

  1. Lungs exhale more CO2 than usually.
  2. H+ ions are pushed into the cells in exchange for potassium – K+.

The second mechanism is responsible for high potassium levels – hyperkalemia – in diabetic ketoacidosis.

Why is bicarbonate low in diabetic ketoacidosis?

One of the phenomena in diabetic ketoacidosis is excessive ketone production. Two ketones – β-hydroxybutyric acid and acetoacetic acid – dissociate in the bloodstream. The result is too many free hydrogen H+ ions, which bind to the free bicarbonate particles:

H+ + HCO3- ⇨ H2CO3

That's why the bicarbonate levels decrease.

What is the difference between ketosis and ketoacidosis?

Ketosis is the presence of ketones in the human blood. It can occur in a healthy person while fasting. The body breaks down lipids (fats) into ketones to get energy.

Ketoacidosis is always a pathological state. It is caused by a lack of insulin in people with diabetes mellitus (DM). In this state, the ketones level is so high that it causes the blood pH to change into a more acidic state. The acidosis state results in subsequent problems, such as dehydration, oxygen deficiency, confusion and/or coma, and gastrointestinal disorders.

Is diabetic ketoacidosis a metabolic acidosis?

Yes, diabetic ketoacidosis is an example of metabolic acidosis. Other examples of metabolic acidosis include lactic acidosis, aspirin or salicylates poisoning, methanol poisoning, and hyperchloremic acidosis as a complication of severe diarrhea.

How do I determine if a patient has ketoacidosis?

To diagnose if a patient has ketoacidosis:

  1. Check if they have abnormally high blood sugar – hyperglycemia.
  2. Check if they have arterial blood pH <7.3.
  3. State if they have bicarbonate <15 mEq/L.
  4. Confirm they have ketones present in the blood and/or urine.

If the patient meets all of those four criteria, they can be diagnosed with ketoacidosis.

Aleksandra Zając, MD
I want to calculate...
diagnosis
Patient's parameters
Glucose over >250 mg/dL (13.8 mmol/L)
No
Serum bicarbonate
> 18 mEq/L (18 mmol/L)
Anion gap
up to 12 mEq/L (up to 12 mmol/L)
Arterial pH
>7.30
Mental state
Alert
Serum ketone
Absent
Urine ketone (3 mmol/L and over)
Absent
The patient has not met any ADA (American Diabetes Association) criteria for diagnosis of diabetic ketoacidosis:
❌ Blood glucose level over 250 mg/dL (13.8 mmol/L)
❌ Serum bicarbonate level less than 18 mEq/L (18 mmol/L)
❌ Blood pH less than 7.3
❌ Elevated serum ketone level
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