Diabetic Ketoacidosis

High ketone levels in the blood can be life-threatening.

• Diabetic ketoacidosis is a life-threatening complication of type 1 diabetes (though rare, it can occur in people with type 2 diabetes) that occurs when the body produces high levels of ketones due to a lack of insulin.
• Diabetic ketoacidosis occurs when the body cannot produce enough insulin.
• The signs and symptoms of diabetic ketoacidosis include:
  • Confusion
  • Frequent urination
  • Nausea and vomiting
  • Abdominal pain
  • Dehydration
• Risk factors for diabetic ketoacidosis are type 1 diabetes, missing insulin doses frequently, or being exposed to a stressor requiring higher insulin doses (infection, etc).
• Diabetic ketoacidosis is diagnosed by an elevated blood sugar (glucose) level, elevated blood ketones, and acidity of the blood (acidosis).
• The treatment for diabetic ketoacidosis is insulin, fluids, and electrolyte therapy.
• Diabetic ketoacidosis can be prevented by taking insulin as prescribed and monitoring glucose and ketone levels.
• The prognosis for a person with diabetic ketoacidosis depends on the severity of the disease and the other underlying medical conditions.

Diabetic ketoacidosis (DKA) is a severe and life-threatening complication of diabetes.

Diabetic ketoacidosis occurs when the cells in our body do not receive the sugar (glucose) they need for energy. This happens while there is plenty of glucose in the bloodstream, but not enough insulin to help convert glucose for use in the cells. The body recognizes this and starts breaking down muscle and fat for energy. This breakdown produces ketones (also called fatty acids), which cause an imbalance in our electrolyte system leading to ketoacidosis (a metabolic acidosis). The sugar that cannot be used because of the lack of insulin stays in the bloodstream (rather than going into the cell and providing energy). The kidneys filter some of the glucose (sugar) and excrete it in the urine.

Typical signs and symptoms of diabetic ketoacidosis include:

• Dry skin and mouth
• Abdominal Pain
• Decreased level of consciousness (anything from drowsiness and confusion to unconsciousness)
• Frequent urination
• Fruity smelling breath
• Shortness of breath
• Deep, rapid breathing (sometimes referred to as Kussmaul breathing)
• Nausea and vomiting
• Dehydration

In general diabetic ketoacidosis occurs because there is not enough insulin to move sugar (glucose) into the cell where it can be used for energy. Besides lack of insulin, certain body stressors combined with diabetes, such as infection or illness, can trigger diabetic ketoacidosis.

Sometimes diabetic ketoacidosis is the first sign of diabetes in people who are not aware they have diabetes. (They have not previously been diagnosed with diabetes.)

People with type 1 diabetes who are not taking their insulin or are getting ill with an infection or other disease are at risk for diabetic ketoacidosis.

Usually, it occurs in people who have type 1 diabetes that are at risk for diabetic ketoacidosis. Although it is rare in people with type 2 diabetes, it can occur.

Because many people who develop diabetic ketoacidosis have multiple underlying illnesses (besides diabetes) diabetic ketoacidosis can lead to significant complications and death. Cardiac arrest and kidney failure are all known complications.

The lifesaving treatment of diabetic ketoacidosis also can lead to the following complications:

• Low blood sugar (hypoglycemia)
• Cerebral Edema (swelling of the brain)
• Low potassium (hypokalemia)

Diabetic ketoacidosis is diagnosed using blood and urine tests, patient history, and physical exams. The typical signs and symptoms along with medical history might suggest the diagnosis. A combination of elevated blood glucose levels, ketones detected in the blood or urine and a lower-than-normal pH level of the blood (indicating acidosis) usually establish the diagnosis. Other blood tests also are ordered to assess the patient's overall status, for example, to check the patient's electrolyte levels, particularly potassium.

Upon physical exam, the patient's pulse rate is often elevated and the blood pressure is lower than normal. The patient may be confused and often will be dehydrated.

If your doctor thinks an infection is present, other tests might be added (chest X-ray, blood cultures).

Diabetic ketoacidosis needs to be treated with several approaches at the same time. The aim is to normalize blood pH, while slowly lowering blood sugar levels, and normalizing all of the electrolytes. This is usually accomplished by giving insulin to the patient as well as electrolyte fluids (such as Normal Saline).

Diabetic ketoacidosis can cause abnormal electrolyte (especially potassium) levels requiring close monitoring of those levels and usually replacing deficient electrolytes. One of the complications of the treatment of diabetic ketoacidosis is a severe fluctuation in potassium levels.

To reverse dehydration IV fluids are given to the patient to replace the fluid loss. The composition of the IV fluids and the speed with which it is infused are important aspects of the care of the patient with diabetic ketoacidosis.

Any underlying illness that may have caused the patient's diabetic ketoacidosis also will be treated such as:

• Infections
• Heart attack
• Other stressors

Supportive care such as oxygen and the patient's usual medications will often be added.

• If you have diabetes, take all of your medications as prescribed by your doctor.
• Learn to recognize the symptoms of elevated blood glucose levels.
• Don't skip insulin doses (an important factor in prevention).
• Test your glucose levels regularly as recommended by your doctor.
• Test your urine at home, especially when you feel ill. This will help detect ketones or elevated sugar in the blood, which should alert you to the possibility of diabetic ketoacidosis.
• Make an appointment with your healthcare professional when you feel sick or if your sugar or ketone levels are higher than normal to prevent further worsening or development of diabetic ketoacidosis.

Diabetic ketoacidosis has a high mortality (death rate) and risk of complications. The prognosis depends on how quickly it is recognized, the underlying medical conditions of the individual, and the underlying precipitating causes of the diabetic ketoacidosis.

Patients with diabetic ketoacidosis usually needs to be treated at the hospital. The person will receive treatment at first by an emergency medicine specialist and once admitted to the hospital by an internist, family medicine specialist or intensivist. Endocrinologists are physicians specializing in the endocrine system and diabetes, and often will be involved in the patient's medical care.