Diabetic ketoacidosis
- Reviewed by Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing
What is it?
Diabetic ketoacidosis is a potentially fatal complication of diabetes that occurs when you have much less insulin than your body needs. This problem causes the blood to become acidic and the body to become dangerously dehydrated. Diabetic ketoacidosis can occur when diabetes is not treated adequately, or it can occur during times of serious sickness.
To understand this illness, you need to understand the way your body powers itself with sugar and other fuels. Foods we eat are broken down by the body, and much of what we eat becomes glucose (a type of sugar), which enters the bloodstream. Insulin helps glucose to pass from the bloodstream into body cells, where it is used for energy. Insulin normally is made by the pancreas, but people with type 1 diabetes (insulin-dependent diabetes) don't produce enough insulin and must inject it daily.
Your body needs a constant source of energy. When you have plenty of insulin, your body cells can get all the energy they need from glucose. If you don't have enough insulin in your blood, your liver is programmed to manufacture emergency fuels. These fuels, made from fat, are called ketones (or keto acids). In a pinch, ketones can give you energy. However, if your body stays dependent on ketones for energy for too long, you soon will become ill. Ketones are acidic chemicals that are toxic at high concentrations.
In diabetic ketoacidosis, ketones build up in the blood, seriously altering the normal chemistry of the blood and interfering with the function of multiple organs. They make the blood acidic, which causes vomiting and abdominal pain. If the acid level of the blood becomes extreme, ketoacidosis can cause falling blood pressure, coma and death.
Ketoacidosis is always accompanied by dehydration, which is caused by high levels of glucose in the blood. Glucose builds up in the blood if there is not enough insulin to move glucose into your cells. During an episode of ketoacidosis, it is common for blood sugar to rise to a level over 400 milligrams per deciliter. When blood sugar levels are so high, some sugar "overflows" into the urine. As sugar is carried away in the urine, water, salt and potassium are drawn into the urine with each sugar molecule, and your body loses large quantities of your fluid and electrolytes, which are minerals that play a crucial role in cell function. As this happens, you produce much more urine than normal. Eventually it may become impossible for you to drink enough fluids to keep up with amounts that you urinate. Vomiting caused by the blood's acidity also contributes to fluid losses and dehydration.
People with type 1 diabetes are at risk of diabetic ketoacidosis. If you have type 1 diabetes, ketoacidosis can occur because you have stopped taking your insulin injections or because your insulin dose is too low. It can be triggered by an infection or severe physical stress, such as an injury or surgery, because your body can need more insulin than usual during these stresses.
Ketoacidosis is less likely to occur in people with type 2 diabetes. In most people who have type 2 diabetes, blood insulin levels usually do not get low enough to signal the liver to make ketones.
In about 25% of children with diabetes, symptoms from ketoacidosis are the first sign that they have diabetes.
Symptoms
Symptoms of diabetic ketoacidosis include:
- frequent urination
- extreme thirst
- dry mouth
- cool skin
- nausea and vomiting with or without abdominal pain.
As blood ketone levels increase, the person's breathing pattern may become slow and deep, and his or her breath can have a fruity odor. A person with ketoacidosis may seem to be tired or confused or may have trouble paying attention. Without prompt treatment in the first day of symptoms, the illness may cause low blood pressure, a loss of consciousness, coma or death.
If you have type 1 diabetes, it is important to frequently measure your blood glucose levels. If your levels are running high or you are prone to ketoacidosis, you will want to test your urine for ketones. If the urine test strip reads "moderate" or "large," it's possible you have ketoacidosis.
Diagnosis
People with diabetic ketoacidosis are always treated in a hospital. Your doctor will test your blood for levels of glucose, ketones, and electrolytes such as sodium and potassium. If you have been taking your insulin without missed doses, your doctor will want to determine if you have an infection.
Expected duration
Symptoms of diabetic ketoacidosis can develop over a period of a few hours, and treatment results in rapid recovery. Commonly, people who develop ketoacidosis will remain in the hospital for one to three days.
Prevention
If you have type 1 diabetes, you usually can prevent diabetic ketoacidosis by following the insulin regimen and diet prescribed by your doctor and by testing your blood glucose regularly. If your body is stressed by an infection, ketoacidosis can develop within hours, and you may not be able to prevent it. It is important for you to check your blood sugar more frequently during an infection, so you can adjust your treatment. It is also important for you to recognize that vomiting and abdominal pain may be signs of ketoacidosis, so that you can get medical help quickly.
To help make sure that you receive proper emergency treatment for diabetic ketoacidosis if you are away from home, wear a medical identification necklace or bracelet that identifies you as a diabetic. This will help emergency personnel to recognize your problem quickly if you are among strangers and you are too sick to speak for yourself.
Treatment
Diabetic ketoacidosis requires treatment in a hospital, often in the intensive care unit. You will receive a large volume of fluids intravenously (through a vein) and insulin to lower your blood sugar and to correct the acidosis. Your blood sugar and acid levels will be monitored frequently, and you will be given potassium supplements to restore your body's supply of this essential mineral. Until your blood chemistry returns to normal, your vital signs (temperature, pulse, respirations, blood pressure) and urine output will be monitored closely. If an infection has triggered your episode of ketoacidosis, antibiotics or other medications will be used to treat the infection.
When to call a professional
If you have type 1 diabetes and feel unwell, check your blood sugar levels often. Also test your urine for ketones. Call your doctor if you have:
- unexplained nausea and vomiting with or without abdominal pain,
- moderate or high levels of urine ketones, or
- your blood sugar is high and you can't lower it by adjusting your insulin dose.
Prognosis
With prompt treatment, more than 95 percent of patients recover from diabetic ketoacidosis.
Additional info
National Institute of Diabetes and Digestive and Kidney Diseases
https://www.diabetes.niddk.nih.gov/
About the Reviewer
Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing
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