Diabetic Ketoacidosis – A diabetes complication you must know about

SIgns & symptoms, causes, diagnosis and management of Diabetes ketoacidosis

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Diabetic ketoacidosis is life-threatening condition, one of the serious most complications of Diabetes Mellitus, which you should watch out for if you’re a diabetic.

It occurs as result of insulin shortage. In absence of insulin, fatty acids breakdown is triggered which in turn leads to accumulation of ketone bodies (byproducts of fatty acids metabolism). The symptoms of Diabetic ketoacidosis occur as a result of ketone bodies accumulation1.

Sometimes, many previously undiagnosed cases of diabetes are first diagnosed during an episode of diabetic ketoacidosis (DKA). Although DKA is more common in type 1 diabetes, it might ensue in type 2 patients too under some circumstances.

DKA is one of the medical emergencies and if not treated appropriately in time it might result in fatality. Hence, it’s important to know how to recognize the problem at home, and how it is treated. Also, you should know what factors can trigger it, so that you can avoid them in future.

Symptoms of diabetic ketoacidosis

  • Nausea and vomiting
  • Abdominal pain
  • Excessive thirst (polydipsia)
  • Excessive urination (polyuria)
  • Increased blood sugar levels (hyperglycemia)
  • Kussmaul respiration2 (deep and labored breathing with gasping)
  • Coffee ground vomiting (the color of vomit is deep red to coffee colored because of blood) in some patients. This occurs because of esophageal erosion.
  • In severe DKA patient may experience lethargy, confusion and stupor. If untreated it might even lead to coma.

Signs of diabetic ketoacidosis

  • Dehydration: There would be signs of dehydration present like reduced skin turgor and dry mouth.
  • Hypovolemia: In severe dehydration hypovolemia may occur. The signs to look for are tachycardia (elevation in heart rate) and falling of blood pressure.
  • Fruity odor: Because of ketone a ketotic/fruity smell is present.
  • Kussmaul respiration: Presented by an increase in respiratory rate.
  • Cerebral edema: It can occur in small children presenting as headache, loss of pupillary reflex, coma. Ultimately it would progress to death. It can be seen in young adults too, however, quite rare in adults.

Causes of diabetic ketoacidosis

A diabetic ketoacidosis is often triggered by another problem superimposed on diabetes. Very often undiagnosed cases of diabetes are first diagnosed during the episode DKA. Underlying problems may include:

  • Infections like influenza, pneumonia, gastroenteritis or urinary tract infections.
  • Insufficient levels of insulin administration. It may occur because of defective pen device, inaccurate method of administration or deliberately taking less insulin like in young individuals who think more insulin may lead to weight gain.
  • Pregnancy
  • Cocaine use
  • Cerebral stroke
  • Myocardial infarction/heart attack

Diagnosis of diabetic ketoacidosis

After a thorough history and physical examination, some investigations would be required to establish the confirmed diagnosis of DKA.

  • Blood sugar: Hyperglycemia would be demonstrated through blood sugar test. In absence of insulin the glucose is unable to enter cells and thus the blood sugar levels are increased.
  • Ketone level: Because of fatty acids (and proteins) breakdown ketone bodies (β-hydroxybutyrate) are released which can be measured in blood. Ketones are also found on urine analysis (acetoacetate).
  • Acidosis: Arterial blood is used to establish acidosis. The pH of blood is on the lower side, hence acidic.
  • Kidney function: Altered levels of urea & creatinine in the blood are indicative of poor kidney function due to dehydration. Levels of other electrolytes are also impaired.
  • Other markers: It’s important to know the underlying cause. Look for infective markers through complete blood count and levels of C-reactive protein. Amylase and lipase are measured to look for acute pancreatitis.
  • Chest X-ray and Urine analysis.
  • CT scan: If signs of cerebral edema are present CT scan is carried out to evaluate the intensity and rule out another possible cause like cerebral stroke.

Management of diabetic ketoacidosis

Diabetic ketoacidosis is a medical emergency and should be treated at an intensive care unit (or a unit capable of dealing high dependency emergencies).

The management protocol requires that the lost fluids/electrolytes are replaced in the body, level of blood sugar is regulated to normal and ketone production is curbed.

1. Fluid replacement

The severity of dehydration decides the quantity of fluid to be infused. When there is severe dehydration, hypovolemic shock, or altered sensorium a quick saline infusion is mandated. The replaced amount is about 1 liter in adults and 10ml/kg in children. In moderate dehydration slower but calculated rehydration can be given, where saline is the fluid of choice. In mild cases of ketoacidosis where dehydration is minimum with no vomiting oral rehydration or can be given, along with subcutaneous insulin instead of intravenous. The patient should be kept under strict supervision throughout.

In cases of cardiogenic shock where heart is unable to pump enough blood leading to decrease in blood pressure and insufficient blood supply to organs, patient must be treated in an ICU. Central venous pressure monitoring is initiated with the help of central venous catheter. Drugs are given to improve the blood pressure and heart pumping.

2. Insulin infusion

There are two separate protocols that are commonly followed. One requires infusion of a bolus dose of 0.1 unit/kg insulin. However, the bolus dose in only administrated if potassium levels are higher than 3.3 mmol/l as insulin administration at lower levels of potassium can further reduce the levels to perilous situation.

Another protocol is to give 0.1 unit/kg on insulin is given per hour. The insulin dose is gradually changed depending upon the fall in blood sugar levels.

3. Potassium replacement

Potassium levels can decrease significantly during insulin administration. Insulin leads to redistribution of potassium into the cells. Hypokalemia that follows can lead to irregularities of heart rate. Hence, it’s important to monitor heart rate and potassium levels. Potassium is added to the IV fluids as soon as the levels are below 5.3 mmol/l. Insulin infusion may have to be stopped if potassium levels fall below 3.3 mmol/l.

4. Bicarbonate

The role of bicarbonates in diabetic ketoacidosis treatment is debated. Although some guidelines recommend bicarbonate infusion to treat acidosis, there is no evidence that it can actually improve the prognosis. In fact bicarbonate may even worsen the acidosis inside the cells. Thus their use is avoided by some guidelines.

5. Manage cerebral edema

If cerebral edema is present along with coma patient is treated in ICU under close observation and artificial ventilation. Slow fluid administration is done. There are no specific guidelines for cerebral edema in DKA, but IV mannitol and 3% hypertonic saline can be used.

Prevention of diabetic ketoacidosis

While Diabetic ketoacidosis is a severe condition it can be prevented by adhering to a simple set of rules for the diabetics-sick day rules. Clearly defined instructions are given to the diabetics to self-treat when feeling unwell. The patient instructed about the extra amount of insulin needed if sugar levels are uncontrolled, about the diet and instructions to handle conditions like infections. Also, the patient must know when to seek medical attention.