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Article disclaimer

Compiled and edited by Lahle Wolfe

Sources

National Diabetes Information Clearinghouse

Wikipedia, Metabolic Acidosis

E-Medicine

Web-MD

Portions of this article (revised) came from Wikipedia.org.  


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WARNING!!

You cannot treat DKA yourself simply by giving more insulin.

The improper treatment of DKA can result in complications that may even lead to death!


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Related information:  Hyperglycemia


What about ketones that are produced when dieting?

DKA is NOT the same thing as "benign dietary ketosis."  Ketones can appear in the urine from either hyperglcemia, or from certain kinds of diets including low-carb diets and very low- calorie diets.

People with type 1 diabetes, and those with type 2 on insulin sensitizing agents or insulin should not adhere to low-carbohydrate diets except under the direct supervision of a qualified medical professional because it may not be possible for the patient to determine the source of ketones registering in the urine.


Did you know? that...

... that thanks to modern fluid management, the mortality rate of DKA is about 2% per episode? Before the discovery of insulin in 1922, the mortality rate was 100%.

...  DKA is seen primarily in patients with type 1 (insulin-dependent) diabetes with about 20-40% of type 1 diabetic patients initially being in DKA when diagnosed?

...  DKA tends to occur most often in individuals younger than 19 years of age but it can occur in diabetic persons of any age?


IOH Mini Medical Dictionary

Acidosis (ac·i·do·sis): (as”i-do´sis)  The accumulation of acid and hydrogen ions or depletion of the alkaline reserve (bicarbonate content) in the blood and body tissues, resulting in a decrease in pH.  

Diabetic Ketoacidosis (DKA):  Metabolic acidosis from the accumulation of ketones due to severely depressed insulin levels.  Diabetic ketoacidosis (DKA) results from grossly deficient insulin availability, causing a transition from glucose to lipid oxidation and metabolism.

Hyperchloremia: 
(hy·per·chlor·emia) An excess of
chloride in the blood.

Hypokalemia:  A potentially fatal condition in which the body fails to retain sufficient potassium to maintain health. The condition is also known as potassium deficiency; hypokalemia is usually indicative of a systemic potassium deficit).

Hyponatremia: The electrolyte disturbance hyponatremia exists when the sodium level in the plasma falls below 135 mmol/l. It is an abnormality that can be seen in isolation or, as most often is the case, as a complication of other medical illnesses.

Metabolic:  Any of the various kinds of acidosis in which the acid-base status of the body shifts toward the acid side because of loss of base or retention of acids other than carbonic acid (fixed or nonvolatile acids), in contrast to respiratory acidosis. Called also nonrespiratory acidosis.


Additional Resources

American Family Physician: Diabetic Ketoacidosis

Family Doctor:  DKA: What is it and how to prevent it

 

islets of hope diabetes medical library                      back to main "Complications" page

Long-Term Complications of Diabetes                                                     printable version of this article

Diabetic Ketoacidosis (DKA)
Symptoms, Causes, Diagnosis, Treatment & Prevention


IOH Health Tip:  Urinary tract infections (UTIs) are the single most common infection associated with DKA.

Mini Site Index
What is Diabetic Ketoacidosis (DKA)?
Diagnosis
Warning Signs and Symptoms of DKA
Clinical Symptoms
Causes
Why it is Important to Call Your Doctor
When to Call Your Doctor
DKA in Type 2 Diabetes
Ketone Test Strips
Treatment of DKA
Advanced DKA
Nonketotic Hyperosmolar Coma
Complications of DKA
Why Hospitalization? Why can’t I just take more insulin on my own?
Living Smart:  Preventing DKA
 

What is Diabetic Ketoacidosis (DKA)?

Also, see Lactic Acidosis and Metabolic Acidosis.

DKA is a state of severe or absolute insulin deficiency (not enough, or no insulin circulating in the blood stream).  Due to the lack of sufficient insulin, the body (tissues, cells, muscles, fat, and the liver, etc.) cannot uptake glucose (move glucose from the blood stream into cells).  This can result in hyperglycemia (high blood glucose) that can quickly elevate to dangerous levels.

The main cause for the elevation in blood glucose in DKA is because certain hormones (glucagon, growth hormone, and catecholamines) work to enhance triglyceride break down into free fatty acids as the body begins to starve (without the presence of insulin the body cannot use glucose for energy).  Beta-oxidation of these fatty acids increases the formation of ketone bodies (or "ketones"), which can be measured in urine.

During DKA, the body shifts from carbohydrate metabolism (using carbohydrate food eaten by converting it to glucose which is transferred into cells by the action of insulin) to a fat-burning state.    Even though a person may eat large amounts of food, without insulin, the body cannot benefit and use the energy, and weight loss results.  The body shifts into “fasting mode” and begins to metabolize fat (use stored fat as energy).  This is why persons newly diagnosed with type 1 diabetes have often experienced weight loss despite an increase in appetite.  

   


Diagnosis

Diagnostic criteria for DKA include (but is not limited to):  hyperglycemia, hyperketonemia, and metabolic acidosis (see IOH’s Mini Medical Dictionary in the sidebar). The initial plasma glucose level is usually 400 to 800 mg/dL (22.2 to 44.4 mmol/ L), but can be lower.  A diagnosis of DKA may also be made if the person’s urine or blood is strongly positive for glucose and ketones.  

Warning Signs and Symptoms of DKA

IOH Health Tip:  One of the most common complaints from children in DKA is abdominal pain – pay attention to tummy aches especially when blood glucose levels are high, or ketones are present in urine.

DKA may present with any of the following symptoms:

  • Hyperglycemia – Elevated blood glucose, which may include symptoms of excessive thirst, frequent urination, excessive hunger, headache, stomach ache, lethargy, night bed wetting, vomiting/nausea, weakness, confusion, weight loss, dehydration, decreased perspiration, shortness of breath.
     
  • Symptoms of Associated Conditions or Infections – Which may include fever and/or chills, abdominal pain, shortness of breath, chest pain, dysuria (frequent urination), urinary tract infection (UTI).
     
  • Physical Symptoms and Signs – Dry skin, weight loss, dry mouth, eyes, and mucous membranes, decreased skin turgor (signs of dehydration), poor coordination, shortness of breath, hollow eyed or general appearance of being ill, excessive hunger and thirst, frequent urination.
     
  • Vital Signs – Tachycardia (irregular heartbeat), hypotension (low blood pressure), tachypnea (rapid breathing), hypothermia (reduced body temperature), and fever may be present if there is an underlying infection.
     
  • Other Signs and Symptoms – Fruity smell on breath (presence of ketones -- Elizabeth smelled like corn syrup when she was heavily into DKA at diagnosis), confusion, stomach pain, coma.  

   


Clinical Symptoms

DKA is typically characterized by hyperglycemia (high blood glucose levels) over 300 mg/dL, but can occur at much lower blood glucose levels.  You should check your urine for ketones whenever blood glucose is 240 mg/dL or higher. 

Causes

DKA is often caused by insufficient insulin being administered (25% of reported cases) or infection or illness requiring a need for more insulin (40% of reported cases).  While a new diagnosis of diabetes (type 1) accounts for approximately 15% of reported incidences of DKA and 20% is attributed to other causes, or a combination of causes previously listed.

Other associated illnesses that may result in DKA include:

  • Myocardial infarction
  • Cerebrovascular accident
  • Complicated pregnancy
  • Trauma
  • Stress
  • Surgery
  • Idiopathic (20-30%)  


Why it is Important to Call Your Doctor

IOH Health Hint:  DKA resulting from severe insulin deficiency accounts for most hospitalizations and is the most common cause of death, mostly due to cerebral edema, seen in pediatric diabetes patients.  An average of 85 children die in the U.S. each year from diabetes complications that for the most part are either directly related to hyperglycemia or hypoglycemia.  Read "Why I started IPump.org and Islets of Hope."

DKA is serious and you should contact your doctor immediately if you suspect DKA or measure moderate (or higher) ketones in your urine.  Many doctors ask you to call the office whenever you have two or more blood glucose readings over 240 mg/dL even without the presence of ketones.  Whatever care instructions your doctor has given to you for handling blood glucose problems  it is very important that you follow his/her advice, especially on sick days.

DKA may require hospitalization to treat.  It probably seems like simply giving more insulin is enough to reverse DKA, but it is not always that simple. Professional care might be necessary to prevent common and potentially lethal complications such as hypoglycemia (low blood sugar), hyponatremia, and hypokalemia (see IOH’s Mini Medical Dictionary in the sidebar).

Since dehydration can accompany, or contribute to DKA, bringing blood glucose down too fast, and rehydrating the body too quickly, can cause serious electrolyte imbalances that can lead to coma or death. Rehydration can also lead to a component of hyperchloremic metabolic acidosis (see IOH’s Mini Medical Dictionary in the sidebar).

It is always best to let your doctor decide how to treat DKA because in addition to carefully administered insulin a person in DKA may also need IV solutions of potassium and fluids, and close medical supervision.  

   


When to Call Your Doctor

  • Stomach or abdomen pain is present
  • Vomiting more than once, or diarrhea 5 or more times in 5 hours (basically, anything that can cause dehydration of electrolyte imbalance should be reported to your doctor)
  • Moderate or higher level of ketones in urine
  • Trouble breathing (slow, shallow, labored in any way)
  • Two or more blood glucose levels higher than 240 mg/dL (or as instructed by your doctor)
  • Blood glucose levels lower than 70 mg/dL (or, as instructed by your doctor)  


DKA in Type 2 Diabetes

Persons with type 2 diabetes rarely suffer DKA, but many may have ketone formation and acidosis (usually mild) because of a decrease in food intake and a marked decrease in insulin secretion due to severe and chronic hyperglycemia . These patients usually will not require insulin after the acute metabolic event is corrected.  


Ketone Test Strips

Test strips for ketones are available over-the-counter for about $10.00 per 100 strips and most insurance plans will cover the cost.  Anytime blood glucose levels are over 240 mg/dL most doctors advise ketone testing, especially during times of stress or illness.  Most doctors will advise their patients to call immediately whenever ketones registered in the moderate range or higher. 

Important Information About Ketone Test Strips!  Test strips do not last long after they are opened.  Be sure to mark the container with the date opened and discard after thirty (30 days) regardless of the package expiration date. 

Since the kind of test strips that are available commercially (over-the-counter) react with acetoacetic acid (and weakly with acetone) but do not react with b-hydroxybutyric acid they may significantly underestimate the amount of ketone bodies present.  If in doubt – CALL YOUR DOCTOR!  

   


Treatment of DKA

DKA usually requires hospitalization and close medical supervision.  DKA can induce coma or death, is serious and should be considered a potentially life-threatening medical emergency.  DKA must be treated appropriately because improper treatment (for example, a patient self-treating with large amounts of insulin) can also cause severe, life-threatening problems.

Treatment of DKA consists of isotonic fluids to rapidly stabilize the circulation, continued intravenous saline with potassium and other electrolytes to replace deficits, insulin to reverse the ketoacidosis, and careful monitoring for complications.

The major treatment goals for DKA are:

  • Rehydration
  • Correction of hyperglycemia and hyperketonemia
  • Prevention of hypokalemia during treatment
  • Identification of, and treatment for, any infection
  • Diagnosis (if applicable) of type 1 diabetes if previously unknown.


Advanced Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA), if it progresses and worsens without treatment, can eventually cause unconsciousness from a combination of severe hyperglycemia, dehydration, shock, and exhaustion. Coma only occurs at an advanced stage, usually after 36 hours or more of worsening vomiting and hyperventilation.

In the early to middle stages of ketoacidosis, patients are typically flushed and breathing rapidly and deeply.  Visible dehydration, shallower breathing, and rapid heart rate are often present when coma is reached.


Metabolic Acidosis

Metabolic acidosis is a state in which the blood pH is low (under 7.35) due to increased production of H+ by the body or the inability of the body to form bicarbonate (HCO3-) in the kidney. Its causes are diverse, and its consequences can be serious, including coma and death. Together with respiratory acidosis, it is one of the two general types of acidosis.  


Nonketotic Hyperosmolar Coma

Nonketotic hyperosmolar coma usually develops more insidiously than DKA because the principal symptom is lethargy progressing to loss of consciousness, rather than vomiting and an obvious illness. Extreme hyperglycemia is accompanied by dehydration due to inadequate fluid intake. Coma from NKHC occurs most often in patients who develop type 2 or steroid diabetes and have an impaired ability to recognize thirst and drink.

The diagnosis is usually made when a chemistry screen performed shows extreme hyperglycemia (often above 1800 mg/dL and dehydration. The treatment consists of insulin and gradual rehydration with intravenous fluids.


Complications of DKA

The mortality rate with DKA is approximately 10%.  Whether a person is also hypotensive (has low blood pressure) or lapsed into coma adversely affects prognosis with DKA.  The major causes of death are circulatory collapse, hypokalemia, and infection.  Acute cerebral edema, is rare but a frequently fatal complication and occurs primarily in children more often than in adolescents and young adults.


Why Hospitalization?

Why can’t I just take more insulin on my own?

IOH Health Tip:  It is dangerous for anyone to try and self-treat DKA simply by administering insulin.

Treating DKA is complicated and requires frequent patient monitoring to adjust fluids, insulin, and electrolyte levels.  Blood glucose needs to be monitored hourly to assess how the patient responds to insulin and to make appropriate adjustments to induce a gradual decline in blood glucose. 

Ketone levels will probably be corrected within several hours if insulin is given in correct doses to lower blood glucose. Plasma pH and bicarbonate usually improve significantly within 6 to 8 hours, but the return of a normal plasma bicarbonate level may take 24 hours.

When blood glucose falls to 250 to 300 mg/dL (13.88 to 16.65 mmol/L), glucose is added to the IV fluids to reduce the risk of hypoglycemia (low blood glucose). The insulin dosage may then be reduced, but the continuous IV infusion of regular insulin should be maintained until plasma and urine are consistently negative for ketones. Once the patient is stabilized he/she will be switched to subcutaneous regular insulin every 4 to 6 hours, however, any lapse in insulin therapy during the first 24 hours after recovery from DKA may result in a rapid resurgence of hyperketonemia.

   


Living Smart:  Preventing DKA

  • Be sure you have a sick day care plan from your doctor BEFORE you are sick.  During an illness follow the instructions and stay in close contact with your doctor.
  • Report all illness and infections to your doctor immediately.
  • Be sure you understand when to test for ketones, and when your doctor expects you to call in with the results.
  • Know your blood glucose target ranges and when your doctor expects you to report troubles (usually when two or more blood glucose readings are outside your target range in a certain time period).
  • Keep well hydrated while sick and during exercise.
  • Check your blood glucose levels often, and more frequently during times of stress (travel, trauma, upset), and on sick days.
  • Never attempt to treat DKA yourself.  

 

   

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Page Updated 05/12/2006