usually happens because your body doesn't have enough insulin. Your cells can't use the sugar in your blood for energy, so they use fat for fuel instead. Burning fat makes acids called ketones and, if the process goes on for a while, they could build up in your blood. That excess can change the chemical balance of your blood and throw off your entire patients with type 1 diabetes mellitus and develops when insulin levels are insufficient to meet the body's basic metabolic requirements. DKA is the first manifestation of type 1 DM in a minority of patients. Insulin deficiency can be absolute (eg, during lapses in the administration of exogenous insulin) or relative (eg, when usual insulin doses do not meet metabolic needs during physiologic stress) The therapeutic goals of DKA management include optimization of 1) volume status; 2) hyperglycemia and ketoacidosis; 3) electrolyte abnormalities; and 4) potential precipitating factors. The majority of patients with DKA present to the emergency room. Therefore, emergency physicians should initiate the management of hyperglycemic crisis while a physical examination is performed, basic metabolic parameters are obtained, and final diagnosis is made. Several impoant steps should be followed in the early stages of DKA management: collect blood for metabolic profile before initiation of intravenous fluids; infuse 1 L of 0.9% sodium chloride over 1 hour after drawing initial blood samples; ensure potassium level of >3.3 mEq/L before initiation of insulin therapy (supplement potassium intravenously if needed); initiate insulin therapy only when steps 1-3 are executed. Ref Harrison 20th edition pg 980