The Down Low on DKA

Everything you Need to Know about Diabetic Ketoacidosis

What is DKA?

Diabetic ketoacidosis is a life-threatening complication that arises when the body has a severe shortage of insulin. When insulin levels are insufficient, the body begins to break down fat for energy, producing ketones. Ketones are acidic byproducts of fat metabolism. In normal circumstances, insulin helps regulate the levels of ketones in the body. However, without enough insulin, ketone levels can become dangerously high, leading to a condition known as ketoacidosis.

Diabetic Ketoacidosis: Symptoms and Causes

Recognizing the symptoms of severe DKA is crucial for prompt intervention and treatment. The symptoms of DKA can develop rapidly and may include:

Excessive Thirst

Dehydration is a common side effect of DKA. Feeling constantly thirsty and needing to drink more fluids than usual. The state of DKA causes an average of six to nine liters of fluid loss. 

Frequent Urination

Passing large amounts of urine more frequently than usual.

Extreme Drowsiness

Some individuals afflicted with DKA experience brain fog or a slight change in mental status, ranging from confusion to unconsciousness, or simply feeling extremely tired.

High Blood Sugar

Elevated blood glucose levels may result in symptoms such as fatigue, blurred vision, and headache. 

Important note: Although DKA is typically associated with high blood sugar, it can also occur when your blood sugar is low due to a lack of insulin, but this is less common.

Nausea and Vomiting

Persistent nausea, vomiting, and stomach pain are often accompanied by abdominal cramping.

Deep, Labored Breathing

In addition to abdominal pain, rapid and profound breathing is often described as "air hunger" and can be a common symptom of DKA. 

Fruity Breath Odor

Another side effect may be a distinctive fruity or acetone-like odor on the breath due to the presence of ketones.
Interesting Fact: If an individual’s breath smells like acetone, the same fruity odor as nail polish remover, it may be a sign of high ketone levels in your blood. This is often associated with type 1 diabetes, but can also be seen in people with type 2. 

It's important to note that only some people with DKA will experience all of these symptoms, and the severity of symptoms can vary from person to person. Some other less common symptoms experienced with DKA include: 

• Dry skin and mouth
• Flushed face
• Fruity-smelling breath
• Muscle stiffness or aches
• Headaches

How Does DKA Happen?

Causes of DKA

Several factors can contribute to the development of DKA in individuals with type 1 diabetes:

Insulin Deficiency

The primary cause of DKA is insufficient insulin in the body. This can occur due to missed insulin injections, insulin pump failure, or inadequate insulin dosage.

Illness or Infection

Infections, such as pneumonia or influenza, can increase the body's demand for insulin, leading to a relative insulin deficiency. It's important to monitor blood glucose levels regularly, especially during times of illness or stress, to prevent DKA.

Stress or Trauma

Physical or emotional stress, such as surgery or trauma, can trigger the release of stress hormones like cortisol, which can interfere with insulin absorption.

Undiagnosed Diabetes

In some cases, DKA may be the first indication of undiagnosed Type 1 Diabetes, especially in children and adolescents.

Urinary Tract Infection (UTI)

A urinary tract infection may also be a cause of diabetic ketoacidosis or other bacterial infections, such as pneumonia. 

Signs of a UTI include: 

• A strong odor
• A strong urge to urinate that won’t go away
• A burning feeling when urinating
• Cloudy, red, rust or pink colored urine
• Pain in the pelvis

Interesting Fact: More than half of African Americans newly diagnosed with DKA, also have signs of type 2 diabetes or atypical diabetes (ketosis prone). A recent study from ScienceDirect on diabetic ketoacidosis discovered that “African Americans have a slight preponderance of type 1 diabetes, while Hispanics mainly have type 2.”

What to Do If You Suspect DKA

If you suspect that you or someone you know is experiencing DKA, it's essential to take immediate action:

1. Check Blood Glucose and Ketone Levels: Test blood glucose levels using a glucose meter; also, test ketones using a ketone meter or a urine test. If blood glucose levels are elevated and ketones are present in the urine or blood, it may indicate DKA.

2. Hydrate: Drink plenty of water or other sugar-free fluids to prevent dehydration and help flush any ketones that may be present. Rehydrating is crucial, but avoid sugary drinks, which can further elevate blood glucose levels.

3. Insulin Treatment: If possible, administer insulin as a health care provider prescribes. If using an insulin pump, check for proper functioning and consider switching to injections if necessary. Any high blood sugar level should be monitored closely. Insulin infusion is a standard treatment for DKA, in which the patient receives a fixed amount of insulin intravenously. 

4. Seek Medical Attention: DKA requires immediate medical intervention. Contact a healthcare provider or go to the nearest emergency room for treatment. DKA treatment typically involves intravenous fluids, insulin therapy, and electrolyte replacement.

Preventing DKA

While low blood sugar levels are hazardous, DKA can be a life-threatening health problem of type 1 diabetes, often considered a medical emergency. It's often preventable with proper diabetes management. Here are some tips for preventing DKA:

Monitor Blood Glucose Levels

Check blood sugar levels regularly, especially during illness or times of stress. Aim to keep blood glucose levels within the target range your healthcare provider recommends. A blood sugar level should typically be taken every two hours when sick. 

Take Insulin as Prescribed

Adhere to your insulin regimen as your diabetes care provider prescribes. Make sure to consult a healthcare professional before skipping insulin doses or altering your dosage.

Stay Hydrated

Drink plenty of water throughout the day to prevent dehydration. Avoid sugary beverages and alcohol, which can affect blood glucose levels and hydration.

Follow Sick Day Guidelines

During illness, follow sick day rules provided by your healthcare team. This may involve adjusting insulin dosages, watching for ketones, monitoring high blood sugar levels and seeking medical attention.

High Ketone Warnings

When the body doesn’t have enough insulin to work with its glucose, the body suffers from a lack of energy. Ketone bodies are a byproduct of fat metabolism that the liver produces as an energy source. When glucose is unavailable and ketones are present, there is also a risk for metabolic acidosis, a severe electrolyte disorder that occurs with too much acid in the body’s fluids.

The American Diabetes Association defines blood-based ketone (BohB) measurements as the preferred test for correctly diagnosing diabetic ketoacidosis.

Ketone Test

Individuals are encouraged to test for ketones through a urine ketone test or a blood test. Both tests provide real-time results.

Important to Know: The National Institutes of Health reports that cerebral edema is the most severe health problem of DKA, with a mortality rate of 20-40%. DKA can cause decreased blood flow to parts of the brain. 

Arterial Blood Gases Test

Arterial blood gas (ABGs) test measures various blood components, including pH, oxygen, carbon dioxide and bicarbonate. Low biocarbonate, or low pH signs are often associated with DKA. 

Other tests for DKA may show depleted potassium levels, due to the lack of insulin which produces hyperglycemia. Physicians should watch serum potassium levels before starting insulin therapy. If the serum potassium levels drop too low, potassium should be administered intravenously. 

DKA Treatment

Diabetic Ketoacidosis is a forbidding complication that can be scary for those experiencing it and their loved ones. It can affect those with juvenile diabetes, adult onset type diabetes, and insulin dependent diabetes mellitus, type 1 or 2. Still, with all things, knowledge is power, and your best resource for combatting DKA is to watch for the warning signs. 

Recognizing the symptoms of DKA, understanding its causes, if you may be at higher risk, and knowing the proper treatment are essential for effectively managing this potentially life-threatening condition. 

With proper diabetes management, a simple blood glucose test in the emergency department, and timely medical help, the risk of DKA can be minimized, allowing individuals with Type 1 Diabetes to live healthy and fulfilling lives.