It’s hard enough to manage diabetes on a daily basis without having to worry about possible complications. However, one of the most serious acute complications of diabetes is diabetic ketoacidosis, or DKA, for short. Left untreated, DKA can quickly escalate and have serious consequences, including coma and death. Fortunately, with an understanding and awareness of DKA, you can stop it in its tracks.
Why does DKA develop in the first place? It starts with insulin, or rather, a lack of insulin. Quick recap: insulin is necessary for glucose (sugar) to move from the bloodstream into the tissues and cells of the body for fuel. A lack of insulin leads to a buildup of glucose in the blood. The cells and tissues aren’t getting the fuel that they need, so the liver responds by releasing stored glucose in an attempt to “feed” the body. As a result, glucose levels climb even higher.
At this point, the hope is that insulin comes on the scene via an injection or an infusion from an insulin pump. If there isn’t enough (or any) insulin, though, the body tries to cope with the crisis by doing the following:
· Increasing urination to try and clear out excess glucose
· Burning fat as an alternate source of fuel for the body
The breakdown of fat for fuel is called lipolysis. Fat is broken down by the liver into glycerol and fatty acids; the fatty acids can be used for energy but can also be used to make glucose through a process called gluconeogenesis. At the same time, substances called ketone bodies are formed. And the formation of ketones is where things can go further awry.
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Ketones are acidic by-products of fat breakdown, or lipolysis. They can be measured in both the urine and the blood. Their presence in situations of weight loss, for example, does not necessarily indicate a problem (think someone on a keto diet). However, ketones combined with high blood glucose and a lack of insulin is of concern. The blood becomes too acidic (the normal pH of blood is usually between 7.35 to 7.45), and continued urination and dehydration can cause losses of electrolytes, such as sodium, potassium and chloride that can affect organ function.
DKA is more likely to occur in people who have type 1 diabetes, but anyone with diabetes can develop it. Again, insufficient insulin is the primary instigator. So why isn’t there enough insulin? There are a number of reasons:
· Someone is “new” to having type 1 diabetes and is “deficient” in insulin
· Insulin injections are missed or deliberately omitted due to, say, an inability to afford insulin, concerns about having hypoglycemia, inconvenience or embarrassment
· Use of expired or spoiled insulin
· An incorrect dose of insulin
· Insulin pump failure
· Eating disorders
· Illness, such as a cold, the flu, pneumonia or a urinary tract infection
· Heart attack or stroke
· Alcohol or drug abuse
· Some medications, such as corticosteroids
The signs and symptoms can often start suddenly, sometimes within 24 hours. Typical symptoms include:
· Frequent urination
· Excessive thirst
· Hyperglycemia (high blood glucose) — often 300 mg/dl or higher
· Nausea and vomiting
· Stomach pain
· Dry skin
· Loss of appetite
· Shortness of breath
· Fruity-smelling breath
You might be wondering why someone might be short of breath with DKA. Rapid breathing or having difficulty breathing in conjunction with DKA is called Kussmaul breathing, and this happens when the body has become too acidic. In the case of DKA, the body tries to compensate for the acidity by expelling more carbon dioxide in an effort to help neutralize the acidity.
And the fruity-smelling breath? That’s due to the presence of acetone, which is a type of ketone — a clear sign of DKA.
If you have any of the above symptoms, it’s time to spring into action. The following steps will help:
· Check your blood sugar often, especially if you’ve been sick, have been under a lot of stress or have not been taking your insulin as prescribed.
· Check for ketones (more on that in a minute) — if you have ketones in your urine, call your doctor.
· Drink plenty of water or carb-free beverages to help flush out ketones.
· Call your doctor if your blood sugars are above 300 mg/dl and are not responding to treatment (meaning, taking insulin).
Your doctor may advise you to head to the emergency room for treatment. Patty Bonsignore, RN, CDE, states, “You should also consider going to the emergency room if you have nausea or are vomiting and don’t have ketone strips.” Also, you may be inclined to do some exercise to help lower your blood sugars. Usually, this is a good idea — but in the presence of ketones and/or symptoms of DKA, exercise will likely cause your blood sugar to go even higher.
DKA is treated with a combination of IV fluids, insulin and electrolyte replacement. Depending on the severity, complications may occur, including hypoglycemia and swelling in the brain, so you’ll be closely monitored in the hospital. You may also need certain tests to get at the underlying cause of DKA. These tests may include blood and urine tests, a chest X-ray and an EKG.
DKA is scary and something to avoid at all costs. Fortunately, knowing the signs and symptoms of DKA and having a plan can help ward it off. Here’s how:
· Talk with your doctor or diabetes educator about having a sick-day plan. Everyone gets sick now and then, so knowing how to adjust your insulin for “sick days,” which, by the way can include not just the flu or a cold, but also extreme stress or dental or medical procedures. Part of your sick-day plan includes a discussion as to when to call your doctor or seek medical attention.
· If you’re ill, check your blood sugar at least four times a day or as often as recommended by your healthcare team. Your doctor may advise you to call if your blood sugar is above 250 mg/dl for more than two readings in a row.
· Take your insulin as prescribed, even if you’re ill and are not able to eat, unless otherwise directed by your doctor. If you are having trouble affording your insulin, talk with your doctor about lower-cost options. You can also find assistance for affording insulin here.
· If you’re ill, do your best to stay hydrated. Drink at least 8 ounces of fluid every hour. If you’re unable to eat or can’t keep food down, alternate sugar-free fluids with carb-containing fluids, such as juice or regular soda, every hour to give you some carb.
· If you are vomiting or have repeated diarrhea, a fever, chest pain or are feeling confused, call your doctor or have someone call for you. Also, don’t hesitate to call your doctor if you’re unsure what to do.
· Keep ketone strips handy. These are available without a prescription at your pharmacy. If your blood glucose is 250 mg/dl or higher, it’s generally recommended to check for ketones. To check for ketones, you pass a strip through a stream of urine. The strip will turn color. Then, hold the strip up to the color chart on the ketone strip container to determine if you have no, trace, small, moderate or a large amount of ketones in your urine. It’s best to call your doctor if you have small, moderate or large amounts of ketones.
· Teach your family, partner or roommates about DKA so that they can recognize possible signs and symptoms and get help for you, if needed.
Want to learn more about dealing with high blood sugar? Read “Strike the Spike II: How to Manage High Blood Glucose After Meals,” “Type 1 Diabetes and High Blood Sugar: Handling Hyperglycemia” and “Managing Hyperglycemia.”
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