Autopilot Lost - Diabetic Ketoacidosis

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Medical Author: Benjamin C. Wedro, MD, FAAEM
Medical Editor: Melissa Conrad Stöppler, MD

We live in a very narrow range of normal. In the range of normal, the body performs well, but once we slip outside the norm, the body spirals slowly out of control. We take most of the internal controls of our body for granted since they are on autopilot, but many people need to fly manually.

The body's cells need two energy requirements to function. The blood stream delivers both oxygen and glucose to the front door of the cell. The the oxygen is invited in, but the glucose needs a key to open the door. The insulin molecule is that key. When we eat, the body senses the levels of glucose in the blood stream and secretes just the right amount of insulin from the pancreas so that cells and the body can function.

People with diabetes don't have the luxury of that auto-sensing. They need to balance the amount of glucose intake with the amount of insulin that needs to be injected. Not enough insulin and the glucose levels in the blood stream start to rise; too much insulin, and they plummet.

The consequences of hypoglycemia (hypo=low, glycemia=glucose in the blood) are easy to understand. No energy source, no function - and the first organ to go is the brain. It needs power to function, and without glucose, the brain shuts down quickly. Confusion, lethargy, and coma occur in short order. It's interesting that brain cells don't need insulin to open their doors to glucose, so when people develop coma from low blood sugar, they waken almost instantaneously upon treatment. Blood sugar is one of the first things checked on scene of a comatose patient, because it's so easy to fix and very embarrassing for an EMT to miss.

And sometimes, too much - is too much. High blood glucose levels, or hyperglycemia, cause a cascade of effects that are damaging to the body in the short and long-term. In the long-term, abnormally high blood sugar causes damage to blood vessels leading to a variety of potential catastrophes; including but not limited to any system that has a blood supply, potentially leading to heart attack, stroke, kidney failure, blindness, and amputations. Add the increased risk of infection associated with hyperglycemia and there is great incentive to keep blood sugars tightly under control.

A rise in glucose because of the lack of insulin has short term consequences as well. Cells can't get at the sugar floating in the blood stream, so they turn to alternative fuel sources to function, but the waste products of this form of metabolism, ketones, make the body more acidic. At the same time, the kidneys sense too much glucose and start spilling it into the urine. Unfortunately, water follows and dehydration quickly occurs. The body tells itself to drink more, but the kidneys rid the body of the water faster. The downward spiral begins. The body becomes more acidic and dehydrated, electrolytes become imbalanced, and a medical emergency is eminent.

• The technical term: diabetic ketoacidosis.
   
• The treatment: fluids, insulin, and education for prevention.

People with diabetes live in a very narrow range of normal. Tight blood sugar control is achieved by taking multiple daily glucose tests and using insulin more frequently during the day, which mimics normal body function allows those with diabetes to live "normal" lives. Autopilot treatments are getting better. How good should diabetic therapy be? When we no longer marvel at elite athletes who have diabetes, and when they don't become a story.