Diabetic Ketoacidosis (DKA)
Islets of Hope Publication DKA-1-2006
WARNING!! You cannot treat DKA yourself simply by giving more insulin. Improper treatment of DKA can result in complications that may lead to death!
IOH Mini Medical Dictionary
Important Medical Disclaimer
All material found in this publication is intended to provide you with general information and should in no way be used as a substitute for professional medical care or advice.
Diabetic Ketoacidosis (DKA)
Islets of Hope Publication DKA-1-2006
3 About Diabetic Ketoacidosis
4 Symptoms of DKA
10 Living Smart: Preventing DKA
IOH Medical Tip: Urinary tract infections (UTIs) are the single most common infection associated with DKA.
About Diabetic Ketoacidosis
What is Diabetic Ketoacidosis (DKA)?
DKA is a state of severe or absolute insulin deficiency. Due to the lack of sufficient insulin, the body cannot (tissues, cells, muscles, fat, and the liver, etc.) cannot uptake glucose, which 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. Beta-oxidation of these fatty acids increases the formation of ketone bodies, which can be measured in urine.
During DKA, the body shifts from carbohydrate metabolism, the normal state, because not enough insulin is present to move glucose into tissues and cells and the body begins to starve. Even though a person may eat large amounts of food, without insulin, the body cannot benefit and weight loss results. The body shifts into “fasting mode” and begins to metabolize fat. This is why persons newly diagnosed with type 1 diabetes have often experienced weight loss.
DKA is not the same thing as benign dietary ketosis which also shows ketones in urine as a result of ketogenic low-carb dieting. Persons with type 1 diabetes, and those with type 2 on insulin sensitizing agents or insulin should not adhere to ketogenic diets except under the direct supervision of a qualified medical professional because it may not be possible for the patient to accurately determine the source of ketones registering in their urine.
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 Medical 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:
typically characterized by hyperglycemia (high blood glucose levels) over 300
mg/dL, but can occur at much lower blood glucose levels. DKA also usually accompanies low bicarbonate
(<15 mEq/L), and acidosis (pH <7.30) with ketonemia and ketonuria.
Causes of DKA
DKA is often caused by insufficient insulin being administered (25% of reported cases), infection or illness requiring a need for more insulin (40% of reported cases). 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:
Why it is Important to Call Your Doctor
IOH Medical 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
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 anytime you have two or more blood glucose readings over 240 mg/dL even without the presence of ketones. Whatever care instructions your doctor has provided for handling DKA, especially on sick days, it is really important that you follow his/her advice.
DKA may require hospitalization to treat. It probably seems like simply giving 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.
Since dehydration can accompany, or contribute to DKA, bringing blood sugars 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.
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
DKA in Type 2 Diabetes
Persons with type 2 diabetes rarely suffer DKA, 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 (glucose toxicity). These persons 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. However, 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.
The major treatment goals for DKA are:
Advanced Diabetic Ketoacidosis
Diabetic ketoacidosis (DKA), if it progresses and worsens without treatment, can eventually cause unconsciousness, from a combination of severe hyperglycemia, dehydration and 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, but visible dehydration, pallor from diminished perfusion, shallower breathing, and rapid heart rate are often present when coma is reached. However these features are variable and not always as described.
If the patient is known to have diabetes, the diagnosis of DKA is usually suspected from the appearance and a history of 1-2 days of vomiting. The diagnosis is confirmed when the usual blood chemistries in the emergency department reveal hyperglycemia and severe metabolic acidosis.
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.
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. It is classically a nursing home condition but can occur in all ages.
The diagnosis is usually discovered when a chemistry screen performed because of obtundation reveals 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% and whether a person is also hypotensive (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 than in adolescents and young adults.
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 the efficacy of the insulin regimens 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.
Preventing Diabetic Ketoacidosis
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 to call your doctor in with the results.
Know your blood glucose target ranges and when your doctor expects you to report troubles (usually when two or morblood 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.
Also, see Islets of Hope Publication HG-2-2006 "Hyperglycemia"
Islets of Hope Publication DKA-1-2006
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