Editing Diabetic ketoacidosis (section)

==Diagnosis==

===Investigations===
Diabetic ketoacidosis may be diagnosed when the combination of [[hyperglycemia]] (high blood sugars), ketones in the blood or on [[urinalysis]] and acidosis are demonstrated.<ref name=JBDS/> In about 10% of cases the blood sugar is not significantly elevated ("euglycemic diabetic ketoacidosis").<ref name=ADA2009/>

A pH measurement is performed to detect acidosis. Blood from a [[vein]] is adequate, as there is little difference between the arterial and the venous pH; arterial samples are only required if there are concerns about oxygen levels.<ref name=JBDS/> Ketones can be measured in the urine (acetoacetate) and blood (β-hydroxybutyrate). When compared with urine acetoacetate testing, capillary blood β-hydroxybutyrate determination can reduce the need for admission, shorten the duration of hospital admission and potentially reduce the costs of hospital care.<ref>{{cite journal | vauthors = Klocker AA, Phelan H, Twigg SM, Craig ME | title = Blood β-hydroxybutyrate vs. urine acetoacetate testing for the prevention and management of ketoacidosis in Type 1 diabetes: a systematic review | journal = Diabetic Medicine | volume = 30 | issue = 7 | pages = 818–824 | date = July 2013 | pmid = 23330615 | doi = 10.1111/dme.12136 | s2cid = 22070325 }}</ref> At very high levels, capillary blood ketone measurement becomes imprecise.<ref name=Misra2015>{{cite journal | vauthors = Misra S, Oliver NS | title = Utility of ketone measurement in the prevention, diagnosis and management of diabetic ketoacidosis | journal = Diabetic Medicine | volume = 32 | issue = 1 | pages = 14–23 | date = January 2015 | pmid = 25307274 | doi = 10.1111/dme.12604 | s2cid = 11923923 }}</ref>

In addition to the above, blood samples are usually taken to measure [[urea]] and [[creatinine]] (measures of [[renal function|kidney function]], which may be impaired in DKA as a result of dehydration) and electrolytes. Furthermore, markers of infection ([[complete blood count]], [[C-reactive protein]]) and [[acute pancreatitis]] ([[amylase]] and [[lipase]]) may be measured. Given the need to exclude infection, [[chest X-ray|chest radiography]] and urinalysis are usually performed.<ref name=ADA2009/>

If cerebral edema is suspected because of confusion, recurrent vomiting or other symptoms, [[computed tomography]] may be performed to assess its severity and to exclude other causes such as [[stroke]].<ref name=Brown2004/>

===Criteria===
Diabetic ketoacidosis is distinguished from other diabetic emergencies by the presence of large amounts of ketones in blood and urine, and marked metabolic acidosis. [[Nonketotic hyperosmolar coma|Hyperosmolar hyperglycemic state]] (HHS, sometimes labeled "hyperosmolar non-ketotic state" or HONK) is much more common in type 2 diabetes and features increased [[plasma osmolarity]] (above 320&nbsp;mosm/kg) due to profound dehydration and concentration of the blood; mild acidosis and ketonemia may occur in this state, but not to the extent observed in DKA. There is a degree of overlap between DKA and HHS, as in DKA the osmolarity may also be increased.<ref name=ADA2009/>

[[Ketoacidosis]] is not always the result of diabetes. It may also result from [[alcoholic beverage|alcohol excess]] and from [[starvation]]; in both states the glucose level is normal or low. [[Metabolic acidosis]] may occur in people with diabetes for other reasons, such as [[poison]]ing with [[ethylene glycol]] or [[paraldehyde]].<ref name=ADA2009/>

The [[American Diabetes Association]] categorizes DKA in adults into one of three stages of severity:<ref name=ADA2009/>
* ''Mild:'' blood pH mildly decreased to between 7.25 and 7.30 (normal 7.35–7.45); serum [[bicarbonate]] decreased to 15–18&nbsp;mmol/L (normal above 20); the person is alert
* ''Moderate:'' pH 7.00–7.25, bicarbonate 10–15, mild drowsiness may be present
* ''Severe:'' pH below 7.00, bicarbonate below 10, stupor or coma may occur

A 2004 statement by the European Society for Paediatric Endocrinology and the Lawson Wilkins Pediatric Endocrine Society (for children) uses slightly different cutoffs, where mild DKA is defined by pH&nbsp;7.20–7.30 (bicarbonate 10–15&nbsp;mmol/L), moderate DKA by pH&nbsp;7.1–7.2 (bicarbonate 5–10) and severe DKA by pH<7.1 (bicarbonate below 5).<ref name=ESPE/>