A young female patient was admitted to the intensive care unit with severe acute respiratory distress syndrome following diabetic ketoacidosis. Intubation and mechanical ventilation were necessary to ensure adequate gas exchange. However, severe hypercapnia with respiratory acidosis persisted despite high ventilatory pressures potentially aggravating ventilatorassociated lung injury. A veno-venous extracorporeal membrane ventilator was used to effectively eliminate carbon dioxide. Within a week, the patient could be weaned from the extracorporeal membrane circuit and mechanical ventilator. This case report highlights the importance of considering ARDS as a consequence of diabetic ketoacidosis. © 2015, Netherlands Society of Intensive Care. All rights reserved.