Diabetic Ketoacidosis

What is Diabetic Ketoacidosis?

Diabetic ketoacidosis (DKA) results from dehydration during a state of relative insulin deficiency, associated with high blood levels of sugar level and organic acids called ketones. Diabetic ketoacidosis is associated with significant disturbances of the body's chemistry, which resolve with proper therapy. Diabetic ketoacidosis usually occurs in people with type 1 (juvenile) diabetes mellitus (T1DM), but diabetic ketoacidosis can develop in any person with diabetes. Since type 1 diabetes typically starts before age 25 years, diabetic ketoacidosis is most common in this age group, but it may occur at any age. Males and females are equally affected.

What are the Symptoms of Diabetic Ketoacidosis?

The warning signs and symptoms of diabetic ketoacidosis may be one or more of these symptoms, vomiting, exessive thirst, confusion, abdominal pain, and dry skin.

What is the Treatment for Diabetic Ketoacidosis? Can You Die from It?

Some people with diabetes can treat diabetic ketoacidosis at home. If a person with diabetes vomits, he or she needs to call 911 or go to the nearest Urgent Care or Emergency Department because the person may die.

A person with diabetes developing diabetic ketoacidosis may have one or more of these symptoms excessive thirst or drinking lots of fluid, frequent urination, general weakness, vomiting, loss of appetite, confusion, abdominal pain, shortness of breath, a generally ill appearance, and dry skin or mouth, increased heart rate, low blood pressure (hypotension), increased rate of breathing, and a distinctive fruity odor on the breath.

When to call the doctor

• If you have any form of diabetes, contact your doctor when you have very high blood sugars (generally more than 350 mg) or moderate elevations that do not respond to home treatment. At initial diagnosis your doctor should have provided you with specific rules for dosing your medication(s) and for checking your urinary ketone level whenever you become ill. If not, ask your health care practitioner to provide such "sick day rules."
• If you have diabetes and start vomiting, seek immediate medical attention.
• If you have diabetes and develop a fever, contact your health care practitioner.
• If you feel sick, check your urinary ketone levels with home test strips. If your urinary ketones are moderate or higher, contact your health care practitioner.

When to go to the hospital

A person with diabetes should be taken to a hospital's emergency department if they appear significantly ill, dehydrated, confused, or very weak. Other reasons to seek immediate medical treatment include shortness of breath, chest pain, severe abdominal pain with vomiting, or high fever (above 101 F or 38.3 C).

Diabetic ketoacidosis occurs when a person with diabetes becomes dehydrated. As the body produces a stress response, hormones (unopposed by insulin due to the insulin deficiency) begin to break down muscle, fat, and liver cells into glucose (sugar) and fatty acids for use as fuel. These hormones include glucagon, growth hormone, and adrenaline. These fatty acids are converted to ketones by a process called oxidation. The body consumes its own muscle, fat, and liver cells for fuel.

In diabetic ketoacidosis, the body shifts from its normal fed metabolism (using carbohydrates for fuel) to a fasting state (using fat for fuel). The resulting increase in blood sugar occurs, because insulin is unavailable to transport sugar into cells for future use. As blood sugar levels rise, the kidneys cannot retain the extra sugar, which is dumped into the urine, thereby increasing urination and causing dehydration. Commonly, about 10% of total body fluids are lost as the patient slips into diabetic ketoacidosis. Significant loss of potassium and other salts in the excessive urination is also common.

The most common events that cause a person with diabetes to develop diabetic ketoacidosis are infection such as diarrhea, vomiting, and/or high fever, missed or inadequate insulin, and newly diagnosed or previously unknown diabetes. Various other causes may include a heart attack, stroke, trauma, stress, alcohol abuse, drug abuse, and surgery. A low percentage of cases have no identifiable cause.

The diagnosis of diabetic ketoacidosis is typically made after the health care practitioner obtains a history, performs a physical examination, and reviews the laboratory tests. Blood tests will be ordered to document the levels of sugar, potassium, sodium, and other electrolytes. Ketone level and kidney function tests along with a blood gas sample (to assess the blood acid level, or pH) are also commonly performed. Other tests may be used to check for conditions that may have triggered the diabetic ketoacidosis, based on the history and physical examination findings. These may include chest X-ray, electrocardiogram (ECG), urine analysis, and possibly a CT scan of the brain.

Home care is generally directed toward preventing diabetic ketoacidosis and treating moderately to elevated to high levels of blood sugar. If you have type 1 diabetes, you should monitor your blood sugars as instructed by your healthcare proffesional. Check these levels more often if you feel ill, if you are fighting an infection, or if you have had a recent illness or injury.

Your health care professinal may recommend treating moderate elevations in blood sugar with additional injections of a short-acting form of insulin. Working with their health care practitioner, people with diabetes should have previously arranged a regimen of extra insulin injections and more frequent blood glucose and urinary ketone monitoring for home treatment as blood sugar levels begin to rise. Be alert for signs of infection and keep yourself well hydrated by drinking sugar free fluids throughout the day.

Fluid replacement and insulin administration intravenously (IV) are the primary and most critical initial treatments for diabetic ketoacidosis. These therapies together reverse dehydration, lower blood acid levels, and restore normal sugar and electrolyte balance. Fluids must be administered wisely - not at an excessive rate or total volume due to the risk of brain swelling (cerebral edema). Potassium is typically added to IV fluids to correct total body depletion of this important electrolyte.

Insulin must not be delayed and must be given promptly as a continuous infusion (not as a bolus - a large dose given rapidly) to stop further ketone formation and to stabilize tissue function by driving available potassium back inside the body's cells. Once blood glucose levels have fallen below 300mg/dL, glucose may be co-administered with ongoing insulin administration to avoid the development of hypoglycemia (low blood sugar).

People diagnosed with diabetic ketoacidosis are usually admitted into the hospital for treatment and may be admitted to the intensive care unit.

Some people with mild acidosis with modest fluid and electrolyte losses, and who can reliably drink fluid and follow medical instructions can be safely treated and sent home. Follow-up must be available with a health care practitioner. Individuals with diabetes who are vomiting should be admitted to the hospital or urgent care center for further observation and treatment.

With aggressive treatment, most people who develop diabetic ketoacidosis can expect complete recovery. Death is rare (2% of cases), but can occur when the condition is not treated. Complications are also possible from associated illnesses such as infection, stroke, and heart attacks. Complications from treatment of diabetic ketoacidosis include low blood sugar, low potassium, fluid accumulation in the lungs (pulmonary edema), seizure, cardiorespiratory arrest, or swelling of the brain (cerebral edema), and death.

Actions a person with diabetes can take to prevent diabetic ketoacidosis include:

• close monitoring and control of blood sugars, especially during times of infection, stress, trauma, or other serious illness;
• taking extra insulin injections or other diabetes medications on time as directed by your health care practitioner; and
• contacting health care practitioner or seeking medical attention promptly as needed.