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Diabetic ketoacidosis is a serious complication of diabetes. Early symptoms include a dry mouth, increased urination, and high blood sugar levels, and later symptoms include fatigue, vomiting, confusion, difficulty breathing and a sweet, fruity odor on the breath.
What is diabetic ketoacidosis?
Diabetic ketoacidosis, or DKA, is a serious complication of diabetes. If the body does not have enough blood glucose (blood sugar) available for energy, it will burn fat instead. This forms ketones in the blood. If the ketones build up, the blood becomes too acidic and can begin to harm the body [1,2].
Early symptoms include dry mouth, increased urination, and high blood sugar levels. Later symptoms are fatigue, vomiting, mental confusion, difficulty breathing, and a sweet, fruity odor on the breath.
Diabetic ketoacidosis can be a life-threatening medical emergency. Treatment is usually administered in a hospital and involves fluids, electrolytes, and insulin.
Call 911 immediately as this requires immediate medical attention.
Diabetic ketoacidosis causes
All diabetic ketoacidosis is caused by a single process that can be initiated by many causes. The body's lack of insulin or resistance to the effects of insulin is primarily responsible for diabetic ketoacidosis.
Role of insulin in the body
Insulin is a hormone produced by the pancreas that informs the body that nutrients, particularly sugars, are present in the blood. It also informs the body to store sugars in the liver and that it does not need to burn fat as energy. When insulin is not present, or the body has severe insulin resistance, the body acts as though it is deprived of energy. This can cause the body to break down fat-producing compounds known as keto acids.
There are a variety of reasons why the body's insulin level may change, which can possibly go unnoticed until you begin experiencing symptoms [4,5]. These include iatrogenic reasons, insulin non-compliance, surgery, initial presentation, intoxication, drugs, infection, and pregnancy.
A recent change in your insulin dose or a change in medication can cause diabetic ketoacidosis. If you do not administer the proper amount of insulin or administer insulin incorrectly, it can cause diabetic ketoacidosis.
If you stop taking insulin or are unable to fill your prescription, the lack of insulin may cause diabetic ketoacidosis. It is important to communicate to your provider if you run out of insulin as the high blood sugar caused by not taking insulin can be lethal.
Surgery can cause an inflammatory reaction as the body prepares for a potential infection. An inflammatory reaction takes energy to maintain and can reduce available sugars in the blood.
Often diabetic ketoacidosis occurs in individuals with diabetes who have never been diagnosed. Because they are unaware of their diagnosis, their blood sugar may be poorly controlled, and their insulin resistance may rise to levels that cause diabetic ketoacidosis.
Consuming alcohol can also precede diabetic ketoacidosis because alcohol can reduce or eliminate the insulin output of the pancreas. For those individuals that take insulin, insulin needs should be adjusted around the consumption of alcohol to avoid diabetic ketoacidosis.
Any drug that affects the ability of the body to metabolize carbohydrates like sugars (e.g. burn for energy) causes a risk for DKA. Common drugs include:
- Steroid medications: This includes corticosteroids or glucocorticoids.
- Antipsychotic medications
- Medications that work on the sympathetic nervous system: These may adjust either respiration or blood pressure like dobutamine or terbutaline.
- Street drugs: These can also have severe effects on blood sugar. Cocaine in any form is known to increase the risk of DKA.
Any infection can cause the body to alter its sugar metabolism and insulin regulation in a way that requires more insulin to maintain a stable and appropriately low blood sugar level.
Pregnancy can cause temporary diabetes. Often without proper prenatal care and follow-up, this new diabetes is unknown to the woman, and if not properly managed, can cause diabetic ketoacidosis.
Who is most likely to be affected
Diabetic ketoacidosis occurs most frequently if you [5,6]:
- Have type 1 diabetes: However, it can also occur infrequently among type 2 diabetes (10 to 30 percent of cases).
- Have type 2 diabetes: The risk is higher if you are of African or Hispanic descent.
- Are elderly
- Have kidney disease or infection: Especially if it is causing either comas or very low blood pressure.
How to treat diabetic ketoacidosis
Treatment for diabetic ketoacidosis requires immediate attention from medical professionals. The drugs, techniques, and monitoring equipment necessary to safely treat diabetic ketoacidosis are almost exclusively found in hospitals and emergency departments.
Once you are in medical care
Diabetic ketoacidosis can be a deadly condition. Once you are in proper care the following will likely occur.
- Fluids provided: You will likely receive fluids, insulin, and potassium or magnesium if your levels are low.
- Hospital admittance: You will likely be admitted into the hospital for further treatment and observation during treatment.
- Duration of stay: It is important to stay in the hospital until you are cleared to leave and have had your blood sugars reduced to a safe level, your fluids replenished, and your electrolytes normalized.
Although all cases of DKA may not be preventable, it is important to monitor your insulin levels and complete safe insulin practices if you have been diagnosed with diabetes. Maintaining healthy lifestyle practices, such as consuming a diet rich in fruits and vegetables and a regular exercise routine can help you remain at a healthy weight and lower your risk of developing diabetes.
When to see a doctor diabetic ketoacidosis
If you suspect that you have diabetic ketoacidosis you must seek emergency medical treatment immediately. Diabetic ketoacidosis and the other conditions it causes (e.g. severe dehydration and hypokalemia) can lead to heart attack, coma, and death and cannot be properly treated at home.
Once a medical professional has confirmed diabetic ketoacidosis
You will be referred to a hospital for further medical treatment.
Questions your doctor may ask to determine diabetic ketoacidosis
- Have you been feeling more tired than usual, lethargic or fatigued despite sleeping a normal amount?
- Have you lost your appetite recently?
- Any fever today or during the last week?
- Are you sick enough to consider going to the emergency room right now?
- Have you experienced any nausea?
Self-diagnose with our free Buoy Assistant if you answer yes on any of these questions.
Ezekiel Richardson is a fourth-year medical student at UPenn, currently applying into Emergency Medicine. He completed an undergraduate degree with a concentration in health disparities at Stanford University. After graduation, he spent a year working in the Maryland Department of Health as a John Gardner Public Service Fellow. Between his third and fourth year of medical school, he completed multiple publications on public health and health accessibility through the Center for Emergency Care and Policy Research Fellowship. He has participated as a teaching assistant in anatomy, histology, and doctoring ethics courses at UPenn. Outside of medical school, he enjoys cooking, volunteering, and traveling in support of his partner’s work on girls’ education in Africa.
- Diabetic ketoacidosis. Mayo Clinic. Published June 12, 2018. Mayo Clinic Link
- Wisse B. Diabetic ketoacidosis. U.S. National Library of Medicine: MedlinePlus. Published January 16, 2018. MedlinePlus Link
- DKA (ketoacidosis) & ketones. American Diabetes Association: Diabetes.org. Published March 18, 2015. Diabetes.org Link
- Kaufmann P, Smolle KH, Fleck S, Lueger A. [Ketoacidosis Diabetic Metabolic Dysregulation: Pathophysiology, Clinical Aspects, Diagnosis and Therapy]. Wiener Klinische Wochenschrift. 1994;106(5):119-127. NCBI Link
- Westerberg DP. Diabetic ketoacidosis: Evaluation and treatment. American Family Physician. 2013;87(5):337-346. AAFP Link
- Nyenwe E, Loganathan R, Blum S, et al. Admissions for diabetic ketoacidosis in ethnic minority groups in a city hospital. 2007;56(2):172-8. NCBI Link