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

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

  • 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 plasmafalls 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.
  •  

    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)
    Symptoms, Causes, Diagnosis,
    Treatment & Prevention

    Islets of Hope Publication DKA-1-2006

     

    Contents

    Page

      3        About Diabetic Ketoacidosis
      3        What is Diabetic Ketoacidosis (DKA)?
      3        Diagnosis

      4        Symptoms of DKA
      4        Warning Signs and Symptoms of DKA
      4        Clinical Symptoms

      5        Causes
      6        Why it is Important to Call Your Doctor
      6        When to Call Your Doctor
      6        DKA in Type 2 Diabetes
      6        Ketone Test Strips

      7        Treatment of DKA
      7        Advanced DKA
      8        Nonketotic Hyperosmolar Coma

      9        Complications of DKA
      9        Why Hospitalization? Why can’t I just take more insulin on my own?

    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. 

    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 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:

    • 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.  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:

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

    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

    • 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, 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:

    • 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 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.

     

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

    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

    This information may be used and distributed freely.  We do ask that you reference www.IsletsofHope.com.