Acute Complications of Diabetes: Diabetic Ketoacidosis (DKA)

by Cindy

Diabetic Ketoacidosis (DKA)

Diabetic ketoacidosis is a serious acute complication of insulin dependent diabetes mellitus.  This condition is most commonly seen in  patients with type 1 diabetes because these patients produce no insulin to help keep rising blood glucose from spiraling out of control.  DKA carries a high risk of serious complications and death when diagnosis and treatment are delayed.  For this reason, all patients with insulin dependent diabetes must understand the potential for this complication, recognize the symptoms and seek medical attention immediately if they suspect diabetic ketoacidosis.

What is Diabetic Ketoacidosis (DKA)?

Diabetic ketoacidosis (DKA) is defined as a states of hyperglycemia, or high blood sugar, that also is accompanied by ketone production and abnormal blood pH.  Patients typically will have blood glucose readings that are higher than 400 mg/dl combined with an abnormal pH and ketone spillage.  However, this condition can develop with blood sugar levels that are less than 400 mg/dl as well.

There are numerous factors that can trigger this acute complication of diabetes that include:

  • Infection:  Infection is the most common event that can cause elevation of glucose levels and precipitate ketoacidosis in diabetic patients. 
  • Illness:  Medical conditions such as stroke, heart attack, appendicitis and more can trigger DKA.  For this reason, all patients who are experiencing this condition must have a complete work up to detect an underlying cause of DKA. 
  • Lack of Insulin:  If patients forget to take or stop their insulin they can develop this acute complication.  In other cases, this may be the first indication of diabetes in a type 1 diabetic patient because they are unaware that the body is not producing insulin. 
  • Stress:  Stress, surgery and other types of conditions can trigger DKA.
  • Medications:  Certain medications, such as prednisone and thiazide diuretics, can increase glucose levels to dangerous ranges. 

Diabetic Ketoacidosis Pathophysiology

Diabetic ketoacidosis occurs due to the combination of lack of insulin, increased hormones that stimulate glucose secretion, and dehydration.  In this setting, insulin is not present to reduce rising glucose levels and the breakdown of fatty acids leads to a scenario of high sugar readings and ketoacidosis.  Patients in DKA can become severely dehydrated due to vomiting and increased urination. 

Diabetic Ketoacidosis Symptoms

There are many ways that diabetes can affect the body during this acute condition.  Symptoms of diabetic ketoacidosis includes:

  • Increased urination
  • Increased thirst
  • Weight loss
  • Vomiting
  • Weakness
  • Lethargy
  • Abdominal pain
  • Confusion
  • Dehydration
  • Fruity breath
  • Abnormal breathing

Diabetic Ketoacidosis Treatment Guidelines

Patients in diabetic ketoacidosis require prompt evaluation in an emergency room setting.  These patients require blood work to determine the severity of this syndrome and should have a complete work up to evaluate for precipitating factors such as infection, heart attack or appendicitis.

Diabetic ketoacidosis management includes:

  • Hospital Admission:  All patients in diabetic ketoacidosis should be admitted to the hospital for treatment and observation.  Many of these patients will be admitted to the Intensive Care Unit (ICU).
  • IV Fluids:  It is important for patients in DKA to receive IV fluids immediately. 
  • Insulin:  Hyperglycemia must be corrected immediately using an insulin infusion.  As glucose levels drop below 250 mg/dl patients should be given an IV infusion that includes 5% dextrose to prevent over-correction and hypoglycemia.
  • Potassium Replacement:  Insulin infusion drives potassium out of the blood and into the cells resulting in low potassium levels.  When potassium levels drop too low, patients can have abnormal heart rhythms and other serious complications.  Potassium levels must be carefully monitored during treatment for diabetic ketoacidosis.
  • Correction of the Underlying Problem:  In most cases infections, such as pneumonia or urinary tract infection, are to blame for DKA and must be treated.  Quick diagnosis of these underlying problems is necessary to correct diabetic ketoacidosis.

Complications of Diabetic Ketoacidosis Management

Diabetic ketoacidosis is a serious condition that carries a high mortality rate, especially when left untreated.  Complications of ketoacidosis include:

  • Cerebral Edema:  Cerebral edema means that there is swelling on the brain and this complication  is extremely dangerous because it can result in neurological damage or death. The reason why cerebral edema occurs in this setting is not well understood.
  • Pulmonary Edema:  Pulmonary edema is a condition where fluid collects in the lungs.  Like cerebral edema, this is a serious condition and occurs most often in diabetic patients with underlying heart problems.  Aggressive IV hydration can cause fluid overload in these patients which results in fluid collection in the lungs.  Patients with pulmonary edema will experience shortness of breath.
  • Abnormal Electrolytes and Blood pH:  Patients will often develop abnormalities that require frequent monitoring and careful corrections of disrupted electrolytes and blood pH. 

How to Prevent Diabetic Ketoacidosis

All patients with insulin dependent diabetes must be educated for the potential of this serious condition.  These patients should understand the symptoms of DKA and the importance of always taking insulin as directed by their physician and to monitor sugar levels closely during times of illness.  Patients should know to seek immediate medical attention for symptoms of DKA to reduce the risk of complications or death from this condition.  Most patients who experience diabetic ketoacidosis will recover without incident but early diagnosis and aggressive management are essential to ensure the lowest risk of complications. 

 

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