Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is an acute, potentially life-threatening complication of diabetes mellitus. For the most part, DKA occurs in people with type 1 diabetes, but it can happen in folks with type 2 diabetes almost as often.

DKA is the result of an inadequate amount of insulin. Insulin allows the body to use its major fuel source (glucose) for energy. Since glucose can no longer be burned, it reaches high levels in the bloodstream. This causes increased urine production and dehydration. About 10% of total body fluids are lost as the patient slips into diabetic ketoacidosis. When there is not enough insulin, the body burns fat instead. Fat breaks down into acids which in turn produce toxic acidic substances known as ketones. These build in the bloodstream causing a dangerous situation. Loss of potassium and other salts which the body needs in the excessive urination is also common.

DKA is therefore a medical emergency which if untreated can result in coma and possibly death. In the early stages, it may be possible to treat DKA at home, but if it is more advanced, management should take place in a properly equipped setting such as a hospital. The keys to prevention of DKA include awareness of its warning signs along with frequent blood glucose monitoring and checking urine or blood ketone levels as needed.

Causative factors

The most common events that cause a person with diabetes to develop diabetic ketoacidosis are:

1. Infection such as diarrhea, vomiting, and/or high fever (40%),
2. Missed, inadequate, or “bad” insulin (25%),
3. New diagnosis or previously unknown diabetes (15%).
4. Various other causes: pregnancy, heart attack, stroke, trauma, stress, alcohol abuse, drug abuse, and surgery.
5. Approximately 5% to 10% of cases have no identifiable cause.

Signs and Symptoms

Typically, symptoms of diabetic ketoacidosis evolve over a 24-hour period. The most common symptoms include:

1. Nausea and vomiting
2. Polydisia (excessive thirst)
3. Polyuria (marked increase in urination)
4. Fruity odor to the breath
5. Abdominal pain (which may be mistaken for conditions like pancreatitis, appendicitis, or gastrointestinal perforation)
6. Increase in blood glucose levels which persists over time

As DKA progresses into its more severe forms, you may also see:

1. Signs of dehydraton (dry mouth, increased heart rate, low blood pressure)
2. Rapid deep labored breathing
3. Coffeeground vomiting
4. Changes in consciousness and/or behavior

Diagnosis

Diagnosing DKA is relatively straightforward. Venous blood and a urine samples are analyzed for gluose and ketones. A high blood glucose level along with the presence of ketone bodies in either the blood or urine are diagnostic of DKA. An arterial specimen for the measurement of blood gases is also taken to confirm acidosis.

Additional blood samples are usually taken to assess electrolytes (sodium, potassium, chloride and bicarbonate) and kidney function (urea and creatinine) which can become compromised because of severe dehydration. Other testing may be done for signs of infection and conditions such as pancreatitis.

A CAT scan may also be performed if cerebral edema or stroke is suspected as may be manifested by lethargy, confusion, muscle weakness, recurrent vomiting, etc.

Classification of Severity

In a position statement, the ADA¹ classifies diabetic ketoacidosis as mild moderate or severe according to laboratory values and symptomatology (see Diagnostic criteria and typical total body deficits of water and electrolytes in DKA and HHS).

The European Society for Paediatric Endocrinology/Lawson Wilkins Pediatric Endocrine Society Consensus Statement on Diabetic Ketoacidosis in Children and Adolescents² states the following: "DKA is generally categorized by the severity of the acidosis, varying from mild (venous pH: <7.30; bicarbonate concentration: <15 mmol/L) to moderate (pH: <7.2; bicarbonate: <10) to severe (pH: <7.1; bicarbonate: <5)."

Treatment

The overall aims of treatment are to restore the body’s metabolic balance, replenish lost fluid and electrolytes, correct the hyperglycemia, and stop ketone production. Depending on the severity of the DKA and the need for close observation, admission to an intensive care unit or similarly equipped facility may be warranted. Primary components of therapy are: fluid, insulin, and potassium replacement along with identification and management of precipitating factors.

The American Diabetes position statement contains very clear protocols for the management of both adults (Management of Adult Patients with DKA) and children (Management of Pediatric (<20 years) Patients with DKA).

Prevention

Data are clear that many cases of DKA are preventable. Since the overall costs of this disorder in terms of morbidity/mortality and the economic strain it places on the health care system (approximately one out of every two healthcare dollars allocated for diabetes are spent) are great, careful emphasis and attention needs to be focused on prevention of DKA. Mechanisms which help include:

1. Better access to quality diabetes care and education
2. Provision of needed management tools such as monitoring equipment, insulin, and syringes.
3. Better education of primary care providers.
4. Improved communications with health care providers during episodes of acute illness.
5. Provision of guidelines as to when to call for help and sick day management.

The Bottom Line

Diabetic ketoacidosis is a serious and potentially lethal complication of diabetes. With the support of your healthcare team, you should be able to detect early warning signs and avoid progression of this devastating diabetes complication. A few guidelines to help:

1. Monitor blood glucose levels frequently. If levels are greater than 240 mg//dl, check urine or blood ketone levels.
2. Never discontinue insulin.
3. Ask your healthcare team for guidelines to assist you in managing sick days and episodes of hyperglycemia.
4. Learn the signs and symptoms of DKA
5. If you are sick, call your doctor if your illness increases blood glucose levels and causes urine ketones. See your doctor or go to an emergency room without delay if there is no improvement in 6–8 hours or you have signs of DKA.
6. When consulting your healthcare team, have your monitoring results available.

References

1. Hyperglycemic Crises in Adult Patients With Diabetes. A consensus statement from the American Diabetes Association.
2. European Society for Paediatric Endocrinology/Lawson Wilkins Pediatric Endocrine Society Consensus Statement on Diabetic Ketoacidosis in Children and Adolescents

For more information

Diabetic Ketoacidosis From eMedicineHealth.
Diabetic Ketoacidosis at Wikipedia.
Ketoacidosis (DKA) From the ADA.