Diabetic Ketoacidosis

Diabetic Ketoacidosis: As Dangerous as it Sounds: Knowing What Diabetic Ketoacidosis is and How to Prevent it Can Save You a Trip to the Hospital

Author: Terri Kordella
Source: Diabetes Forecast, March 2005

When you have diabetes, it’s crucial to make sure there’s enough insulin in your body. One reason is that insulin controls your blood glucose and helps you avoid the complications of diabetes. But there’s another reason: If you don’t have enough insulin, you run the risk of developing a dangerous condition called diabetic ketoacidosis.

Keto-what?

It sounds like something out of a science fiction movie, but diabetic ketoacidosis, or DKA for short, is serious business. Left untreated, it can be fatal.

DKA can occur when you don’t have enough insulin to meet your body’s needs. As your blood glucose goes up, you lose glucose in your urine. When glucose is lost in urine it pulls fluid out with it. If you don’t replace the fluids you lose, you can become dehydrated.

Meanwhile, your body begins burning fat and protein from muscle tissue just to maintain health and energy. Normally your body uses carbohydrate (glucose) for maintenance, but because there isn’t enough insulin in your body, your cells can’t access the glucose in your blood. Your body then resorts to burning fat in an unhealthy way. Your liver becomes involved in fat-burning, and the by-product is ketones. The ketones build up and your blood becomes acidic.

That’s bad news.

As DKA progresses and you become more dehydrated, your body tries to defend itself by rearranging its own chemistry.

“It’s a buffer system,” says Carle Hurst, diabetes nurse educator and center manager at Inova Alexandria Hospital in Alexandria, Va. “As your blood becomes acidic from the ketones, your system starts shifting electrolytes around to counter the acid. You retain sodium and lose potassium, and that’s when it gets dangerous. Your blood becomes a toxic environment for your organs.”

For example, an imbalance of potassium may affect your heart rhythm. Your brain may be affected, too, because it needs electrolytes as well as glucose to function. If your brain isn’t getting either the glucose or electrolytes it needs, you run the risk of a coma.

As DKA first takes hold, you might feel sick to your stomach, very thirsty, and tired. This usually happens over a period of hours or days. From there you may become confused and short of breath, if you don’t get your blood glucose levels down and replenish the fluids in your body, you may eventually need an IV. Untreated DKA can result in coma or death.

Who’s At Risk

The best way to avoid DKA is knowing when you’re at risk for it, says Ronald R Monsaert, MD, associate in endocrinology at the Diabetes and Metabolic Diseases Center of Christiana Care in Wilmington, Del.

According to Monsaert, the risk of DKA is highest when you’re sick.

“DKA often happens when people aren’t eating and they don’t take enough insulin,” he says. “They think that not eating means their blood glucose won’t go up and they don’t need as much insulin, but that’s not the case. When you’re sick, your blood glucose rises.”

If anything, you might need more insulin when you’re sick, so check your blood glucose every 2 to 4 hours when you’re feeling under the weather. In fact, it’s best to have a sick day plan in place before you get sick, so work one out with your diabetes care team.

Your risk of DKA rises when you’re injured or have an infection like a foot ulcer. This is because your body releases stress hormones during illness, injury, or infection, just like it releases stress hormones when you’re on edge emotionally. Stress hormones counteract insulin, so your blood glucose will rise.

Although emotional stress may raise your blood glucose levels, your chances of developing DKA from this are small. Nonetheless, it would be wise to keep tabs on your blood glucose during stressful times.

Then there are the little glitches in life. If your insulin has gone bad or your insulin pump is clogged, your body won’t get the insulin it needs, putting you at risk for DKA.

In general, people with type 1 have a much higher risk of developing DKA than people with type 2. This is because people with type 2 still produce small amounts of insulin to help compensate for high blood glucose when they are sick with things like the flu. In type 1, the body can’t make insulin at all and there’s no way to compensate for it naturally.

DKA is rare in people with type 2. However, if you have type 2 and you are sick with the flu, recovering from injury, or fighting an infection, there is a small chance that you may be at risk for DKA.

If you are at risk for DKA through illness, injury, or infection, check your blood glucose. If it’s elevated, the next step is to check for ketones. You do this by using an over-the-counter urine ketone testing kit. There are blood ketone tests available, but check with your insurance company to see if they are covered.

Hurst notes that your risk of DKA is not proportional to your blood glucose levels. “For some people, it can happen at 180 mg/dl, for others it’s a little higher. Your blood glucose doesn’t have to be up around 400 mg/dl,” she says. When in doubt, check your ketones.

When To Get Help

The American Diabetes Association recommends that you call your doctor if you experience even one symptom of DKA and your blood glucose is over 250 mg/dl. (See “Signs And Symptoms” below for a full list.)

You should also call your doctor if the results of your ketone tests say “moderate” or “large.” When planning your sick-day care, ask your doctor if you should notify him or her if ketone-testing results say “trace” or “small.”

However, it can’t hurt to call your doctor if you are concerned about DKA or nervous about your ketone test results.

“If you pay attention to symptoms, check your blood glucose, and catch DKA early enough, your doctor may be able to help you manage it over the phone,” says Monsaert.

Treatment

High or moderate ketones require immediate treatment. If you have type 1, your doctor may prescribe extra insulin or recommend that you go to the hospital. If you have type 2 and don’t normally take insulin, your doctor may prescribe some for you.

You should drink plenty of fluids to help yourself rehydrate. Check with your doctor to see what kinds of fluids you should drink. It will depend on what your blood glucose level is and whether you need to take extra insulin. If you are vomiting and can’t keep fluids down, get help at once.

The last thing you should do when you have DKA is work out. That will only cause more fat-burning, and not in the good way normally associated with exercise. Even if you take extra insulin, exercise may cancel it out, so rest up.

If you do end up at the hospital, you’ll probably receive IV fluids and insulin. Depending on how long you’ve had DKA and whether you have other health conditions such as high blood pressure or an infection, your hospital stay may last anywhere between 6 hours and 2 days.

DKA is serious business, but you can avoid it if you are aware of the risks, stick with your diabetes care regimen when you’re ill or injured, and keep track of your blood glucose and ketones.

SIGNS & SYMPTOMS

Test for ketones when you have signs of high blood glucose such as:

* Frequent urination

* Intense thirst

* blurry vision

* fatigue

Call your doctor when you experience:

* lack of appetite

* muscle stiffness or aching

* dry mouth

* pains in your abdomen

* vomiting or feeling sick to your stomach

* dry or flushed skin

* difficulty breathing

* feelings of weakness

* sleepiness

* a fruity odor on your breath