Precipitating factors

• Infection. This is the commonest identifiable cause of ketoacidosis reported in the literature, accounting for approximately 35 per cent of all episodes, pneumonia and urinary tract infections being the most frequent types.

• New cases of diabetes. These account for approximately 10-15 per cent of episodes.

• Management errors. These include inappropriate changes in insulin dosage initiated either by the patient or sometimes following medical advice.

• Recurrent ketoacidosis. This affects a small subgroup of patients, the majority being females under the age of 20 years in whom psychological problems lead to discontinuation of insulin.

• Other factors. No precipitating cause is identified in approximately 25-35 per cent of episodes, although this depends on the rigour with which the search is conducted. Ultimately, it must be concluded that insufficient insulin has been administered.

Higher rates of ketoacidosis have been observed in some centres specialising in continuous subcutaneous insulin infusion (CSII). In the Diabetes Control and Complications Trial (DCCT), a higher rate of ketoacidosis was observed in patients receiving CSII than in those on multiple insulin injections. It has been suggested that the small subcutaneous depot of regular insulin in CSII predisposes to the rapid development of ketoacidosis if the infusion is interrupted.

Discontinuation of insulin treatment is a common cause of diabetic ketoacidosis

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