Diabetic ketoacidosis

Definition

Diabetic ketoacidosis is a complication of diabetes that occurs when the body cannot use sugar (glucose) as a fuel source because the body has no insulin or not enough insulin, and fat is used instead. Byproducts of fat breakdown, called ketones, build up in the body.

Alternative Names

DKA; Ketoacidosis

Causes, incidence, and risk factors

People with type 1 diabetes lack enough insulin, a hormone the body uses to process glucose (blood sugar) for energy. When glucose is not available, body fat is broken down instead.

As fats are broken down, acids called ketones build up in the blood and urine. In high levels, ketones are poisonous. This condition is known as ketoacidosis

Blood glucose levels rise (usually higher than 300 mg/dL) because the liver produces glucose to try to combat the problem. However the cells cannot pull in that glucose without insulin.

Diabetic ketoacidosis may lead to a diagnosis of type 1 diabetes, because it is often the first symptom that causes a person to see a doctor. It can also be the result of increased insulin needs in someone already diagnosed with type 1 diabetes. Infection, trauma, heart attack, or surgery can lead to diabetic ketoacidosis in such cases. Missing doses of insulin can also lead to ketoacidosis in people with diabetes.

People with type 2 diabetes can develop ketoacidosis, but it is rare. It is usually triggered by a severe illness. People of Hispanic and African-American ethnicity seem to be more likely to have ketoacidosis as a complication of type 2 diabetes.

Symptoms

The warning signs that you are becoming very sick might include:

• Deep, rapid breathing
• Dry skin and mouth
• Flushed face
• Fruity breath (breath odor)
• Nausea and vomiting
• Stomach pain

Other symptoms that can occur include:

• Fatigue
• Frequent urination or thirst for a day or more
• Mental stupor that may progress to coma
• Muscle stiffness or aching
• Shortness of breath
• Abdominal pain
• Breathing difficulty while lying down
• Decreased appetite
• Decreased consciousness
• Headache

Signs and tests

Ketone testing may be used in type 1 diabetes to screen for early ketoacidosis. The ketones test is done using a urine sample. Ketone testing is usually done at the following times:

• When the blood sugar is higher than 240 mg/dL
• During an illness such as pneumonia, heart attack, or stroke
• When nausea or vomiting occur
• During pregnancy

Other tests that may be done to diagnose ketoacidosis include:

• Arterial blood gas
• Blood glucose test
• Blood pressure measurement
• Amylase blood test
• Potassium blood test

This disease may also affect the results of the following tests:

• CO2
• CSF collection
• Potassium urine test
• Magnesium blood test
• Phosphorus blood test
• Sodium blood test
• Sodium urine test
• Urine pH

Treatment

The goal of treatment is to correct the high blood glucose level by giving more insulin. Another goal is to replace fluids lost through excessive urination and vomiting. You may be able to recognize the early warning signs and make appropriate corrections at home before the condition gets worse.

Most of the time, you will need to go to the hospital. The following will be done at the hospital:

• Insulin replacement will be given.
• Fluids and electrolytes will be replaced.
• The cause of the condition (such as infection) will be found and treated.

Support Groups

Expectations (prognosis)

Acidosis can lead to severe illness or death. Improved therapy for young people with diabetes has decreased the death rate from this condition. However, it remains a significant risk in the elderly, and in people who fall into a coma when treatment has been delayed.

Complications

• Fluid buildup in the brain (cerebral edema)
• Heart attack and death of bowel tissue due to low blood pressure
• Renal failure

Calling your health care provider

This condition can become a medical emergency. Call your health care provider if you notice early symptoms of diabetic ketoacidosis.

Go to the emergency room or call the local emergency number (such as 911) if you experience:

• Decreased consciousness
• Difficulty breathing
• Fruity breath
• Mental stupor
• Nausea
• Vomiting

Prevention

People with diabetes should learn to recognize the early warning signs and symptoms of ketoacidosis. In people with infections or who are on insulin pump therapy, measuring urine ketones can give more information than glucose measurements alone.

Insulin pump users need to check often to see that insulin is still flowing through the tubing, and that there are no blockages, kinks, or disconnections.

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References

Eisenbarth GS, Polonsky KS, Buse JB. Type 1 Diabetes Mellitus. In: Kronenberg HM, Melmed S, Polonsky KS, Larsen PR. Kronenberg: Williams Textbook of Endocrinology. 11th ed. Philadelphia, Pa: Saunders Elsevier; 2008:chap 31.