Diabetic Ketoacidosis

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

Diabetic ketoacidosis (DKA) is a severe and life-threatening complication of diabetes. DKA occurs when the cells in the 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, 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.

What is DKA?

DKA stands for diabetic ketoacidosis, a life-threatening complication of diabetes, most commonly seen in type 1 diabetes, but it can also occur in type 2.

Key signs of DKA include:

• High blood glucose
• Fruity-smelling breath
• Rapid breathing
• Nausea or vomiting
• Confusion or drowsiness
• Abdominal pain

DKA requires urgent treatment to replenish fluids and insulin and electrolyte levels.

What is ketoacidosis?

Ketoacidosis is a condition in which the blood becomes extremely acidic due to the buildup of excess ketones. While diabetic ketoacidosis (DKA) is the most common type, ketoacidosis can also occur in:

• Alcoholic ketoacidosis (in people with chronic alcohol use)
• Starvation ketoacidosis (after prolonged fasting or extreme low-carb diets)

In all forms, ketoacidosis is a medical emergency that needs prompt treatment to prevent serious complications or death.

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.) Understanding the common ketoacidosis causes can help prevent life-threatening complications.

All forms of ketoacidosis result from increased ketone production and acid buildup in the blood, leading to a drop in blood pH (acidosis). In general, the causes of each type of ketoacidosis are as follows:

• Diabetic ketoacidosis (DKA):
  • Insulin deficiency (common in type 1 diabetes)
  • Infection (such as urinary tract infection, pneumonia)
  • Missed insulin doses
  • Uncontrolled blood sugar
  • Severe illness or trauma
  • New-onset diabetes
• Alcoholic ketoacidosis:
  • Chronic alcohol use
  • Poor nutritional intake (starvation)
  • Prolonged vomiting
  • Liver disease
• Starvation ketoacidosis:
  • Prolonged fasting or very low-calorie diets
  • Severe malnutrition
  • Eating disorders (e.g., anorexia nervosa)

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, DKA 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.

Typical signs and symptoms of a more severe 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
• Confusion or drowsiness
• Coma

What are the warning signs of diabetic ketoacidosis?

Early symptoms and signs of DKA include:

• High blood sugar (consistently over 250 mg/dL)
• Presence of ketones in urine or blood
• Unusual thirst or dry mouth
• Increased urination
• Fatigue or weakness
• Fast breathing
• Stomach pain or nausea
• Lightheadedness

These are the warning signs of diabetic ketoacidosis. If two or more of these symptoms are present, especially in someone with diabetes, DKA may be developing, and immediate medical care is needed.

Symptoms of ketoacidosis

In general, symptoms of ketoacidosis that include both diabetic and nondiabetic forms are as follows:

• Nausea and vomiting
• Abdominal pain
• Shortness of breath or rapid breathing
• Fruity-smelling breath
• Mental confusion
• Fatigue or weakness
• Signs of dehydration (dry skin, dizziness)

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).

DKA requires immediate medical treatment in a hospital. The following are the key steps in diabetic ketoacidosis treatment:

• Administering IV fluids to correct dehydration
• Administration of IV insulin to reduce blood glucose and stop ketone production
• Electrolyte replacement therapy, especially potassium, which drops as insulin is given
• Monitoring, which includes frequent checks of blood glucose, ketones, pH, and electrolytes
• Identify and treat the cause, which includes infection, missed insulin dose, etc.

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.

Diabetic ketoacidosis management

Once stabilized, ongoing DKA management focuses on:

• Transitioning from IV to subcutaneous insulin
• Educating on insulin adherence and blood glucose monitoring
• Reviewing causes (such as infection, missed insulin, stress)
• Adjusting insulin regimens and lifestyle
• Regular ketone testing when sick or stressed

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 diabetic ketoacidosis.

Several factors can determine how long it takes to die from diabetic ketoacidosis, including:

• Severity of insulin deficiency
• Person's age and overall health
• Rate at which ketone levels rise
• Presence of underlying infections or illnesses
• Availability and timing of medical treatment

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)

Use the following tips to help prevent diabetic ketoacidosis:

• 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 health care 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.

• Can diabetic ketoacidosis be cured? Diabetic ketoacidosis can be reversed and cured with prompt medical care. However, the risk of recurrence remains if diabetes isn't well-controlled.
• Does drinking water help ketoacidosis? Drinking water can be beneficial mostly in the early stages of ketoacidosis, but it doesn't treat the condition. Water can replenish the fluids lost during dehydration and help flush out excess ketones through urine.
• How do you diagnose DKA? DKA can be diagnosed using blood and urine tests, patient history, and physical examinations.