Diabetes Forecast

Diabetic Ketoacidosis

How to spot and treat DKA

By Erika Gebel, PhD ,

It's one of the scariest complicatons of diabetes: diabetic ketoacidosis, often referred to as DKA. Left untreated, it can lead to coma and death. While it's more common in people with type 1 diabetes, a third of DKA cases occur in those with type 2. Although most cases affect people over the age of 20 and the great majority of DKA cases in kids aren't fatal, this condition is still the No. 1 killer of children and adolescents with type 1 diabetes. And in some instances, people discover that they have diabetes after they land in the hospital with DKA. So it's important to know the signs of DKA—and how to avoid it.

The Chemistry Behind the Crisis

DKA starts with a lack of the hormone insulin. When things are working normally, insulin ushers glucose (a kind of sugar from food) into cells, where it can be converted into energy. But without enough insulin in the body, glucose accumulates in the blood, where it is of little use. Even though there is plenty of glucose around, it can't get into the cells to feed them. The body's response is to drive up blood glucose even more by spurring the liver to break down its glucose stores and to make additional glucose from scratch.

As the body tries to clear the surplus glucose out of its blood through urination, a person may become dangerously dehydrated. At the same time, the body starts to liquidate fat deposits for energy. Fat is indeed rich in energy, but breaking down these stockpiles produces acidic side products called ketones. In high enough concentrations, ketones become toxic by making the blood more acidic. This imbalance is the crux of DKA and gives this complication its name. This increase in blood acidity can severely disrupt the finely tuned chemical processes in your body that keep you living and healthy.

A Related Risk:Hyperosmolar Hyperglycemic State

A more deadly but less common complication of diabetes, which has some overlap in symptoms with DKA, is hyperosmolar hyperglycemic state (HHS). This condition is most common in older people with type 2, although it can also occur in younger people or those with type 1. In HHS, extremely high blood glucose levels (greater than 600 mg/dl)—typically brought on by insufficient medication or an infection—cause frequent urination and extreme dehydration, which can lead, if untreated, to coma or death. Symptoms may also include thirst, confusion or hallucinations, and fever. The main difference from DKA is the absence of ketone production in the body. People with HHS still have enough insulin in their bodies to suppress ketones, so diagnosis usually involves identifying very high blood glucose and dehydration in the absence of ketone-induced acidosis. HHS can take some time to develop, so the best defense is to check blood glucose regularly, especially if you're sick. Treatment of HHS is similar to that for DKA: Hydrate, balance electrolytes, and get blood glucose under control.

Signs and Signals

The most common triggers for DKA are illnesses or infections, which promote the production of certain hormones in the body that counteract insulin. This is why "sick-day rules" focus on taking more insulin when you're ill. The condition may also arise from other events that place stress on the body, such as heart attack and stroke. In addition, missing insulin doses, undetected insulin pump failure, and certain medications can lead to the development of DKA.

DKA can develop rapidly, typically in less than 24 hours. It brings on a range of symptoms. Frequent urination from hyperglycemia results in dehydration and tremendous thirst. Other symptoms include nausea, vomiting, abdominal pain, loss of appetite, and confusion.

Shortness of breath is another DKA symptom. As the body's natural buffering system is overwhelmed by the acidic ketones, this imbalance causes hyperventilation as the body attempts to regulate blood acid levels by getting rid of carbon dioxide in expired air. As the severity of ketoacidosis increases, the smell of a person's breath may take on the fruity tinge of nail polish remover.

High blood glucose levels that don't respond to medication are also a sign of DKA, particularly levels greater than 300 mg/dl. But elevated blood glucose isn't always present with DKA. Some people get what is called "euglycemic DKA," meaning that although their blood glucose is not elevated, they are still producing ketones.

The key to diagnosing DKA is checking ketone levels in the urine. Over-the-counter ketone test kits are available at pharmacies, or a test for ketones can be done at the doctor's office. If you have DKA symptoms, consistently high blood glucose, or persistently high urinary ketones, you should immediately seek emergency care. This is especially true if you have or recently had an illness or infection.

Dealing With DKA

DKA is typically treated in an intensive care unit using a three-pronged approach. Intravenous fluid replacement is necessary to combat dehydration. Electrolytes—which affect the heart, muscles, and nerve cells—are reduced in DKA, so treatment also focuses on bringing them back to healthy levels. Finally, since a lack of insulin brings on DKA, insulin treatment reverses the process. Insulin will bring down blood glucose and halt the acidification of blood by ketones. With prompt treatment, DKA is usually quickly reversed and may require only a day or two in the hospital.

Between 1996 and 2006, there was a 35 percent increase in DKA-related hospitalizations in the United States. Some studies suggest that skyrocketing medical costs may be to blame; people may be putting themselves at risk for DKA by cutting back on insulin to save money. This disturbing trend underscores how essential it is to take care of yourself, especially when you're sick, by monitoring blood glucose; keeping it under control with the right combination of diet, exercise, and medication; being aware of the symptoms of diabetes complications like DKA; and seeking treatment promptly if you need it.



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