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Diabetic Ketoacidosis

Overview

Diabetic ketoacidosis (DKA) is a complication of diabetes mellitus that occurs due to insulin deficiency resulting in increased blood levels of sugar and keto acids, causing the acute symptoms of vomiting, gasping breathing, increased urination, confusion, etc. It is a life-threatening emergency that occurs more commonly in people with type 1 diabetes, but people with type 2 diabetes mellitus can also be affected, often if they have not been diagnosed before.

Your body depends on glucose for energy to perform various processes. Insulin is the transporter that picks up sugar from the blood and transports it to the cells of the body to be used as fuel. In some situations like infections, trauma, pregnancy, etc., the body needs extra energy to deal with the stress using glucose (sugar), which is not transported well into the cells in the absence of insulin. Instead, it (sugar) remains in the blood and needs to be excreted in the urine, often taking all the available water of the body, causing dehydration. The liver gets the signals to make more glucose from the body’s stores, further increasing the blood sugar levels in the blood. The metabolic factory of our body cells switches to obtaining energy from the breakdown of fats, resulting in the production of keto acids as a by-product putting the body in the acidosis state. The natural buffers of the body try to get rid of excess acid by exhaling carbon dioxide (which is an acid), resulting in hyperventilation (increased breathing frequency). The vicious cycle continues if not treated at once.

 

Treatment is directed towards the provision of insulin, correction of hydration status with fluids, replenishing electrolytes, correction of acid-base balance, and correcting the underlying cause. 

Causes

There is an organ called the pancreas in your body that produces insulin. In diabetes mellitus, this function of the pancreas is compromised, and it is not able to produce enough insulin required by the body. So people suffering from diabetes mellitus use medicines that enhance insulin release from the pancreas or insulin formulations to manage their disease. If they forget to take their medicines or insulin, the sugar levels will rise in the blood. Also, in some situations like infections, pregnancy, trauma, surgeries, medications, the body's need for sugars and insulin is increased, which is not available, resulting in diabetic ketoacidosis.

The following are the factors that can cause diabetic ketoacidosis;

·         Problems with insulin therapy

·         An illness or infection

·         Trauma or a surgery

·         Stroke or a Heart attack

·         Pancreatitis

·         Pregnancy

·         Alcohol or drug abuse

 

·         Some Medications

Risk Factors

The following risk factors can increase your chances of diabetic ketoacidosis;

·         Having type 1 diabetes mellitus (DM)

·         Having an undiagnosed type 2 diabetes mellitus (DM)

·         Missing insulin shots or using expired insulin

·         Having DM and starting new medicines like steroids or diuretics

·         Having DM and using illicit drugs like cocaine

 

·         Having DM and gets infection, stress, etc

Epidemiology

Although diabetic self-care is excessively emphasized, DKA is still responsible for 14%  of hospital admissions and 16% of diabetic-related fatalities. Young people with type 1 diabetes are more affected by DKA and account for 50% of diabetes-related hospital admissions. DKA is more common in White Americans due to the increased incidence of diabetes in them. 

Diagnosis

Suppose you are a diabetic patient and feel a deterioration in your general condition or, more specifically, have signs and symptoms of DKA. In that case, you should check your blood sugar levels at home. If they are higher than 250mg/dl, you should check the ketones in urine with a ketone testing kit. The presence of ketones is a warning sign of DKA, and you must visit your healthcare provider or even the emergency department if a physician is not available.

The doctor will take your history and examine you for the signs of DKA, especially signs of dehydration like dry lips and tongue, decreased skin turgor, low blood pressure, increased heart rate. He may order some tests like;

·         Blood glucose levels

·         Blood Amylase and lipase levels to check for pancreatitis

·         Urine dipstick

·         Ketone levels

·         Arterial blood gases levels (ABG)

·         Complete blood count (CBC)

·         BUN and creatinine levels

·         Urine and blood cultures

·         Electrocardiogram to check for heart attack

Imaging studies

·         Chest Xray can show infection in the lungs

 

·         CT scan or MRI of the head can show signs of cerebral edema

Differential Diagnosis

Some other conditions may look like DKA;

·         Acute Pancreatitis

·         Hyperosmolar Coma

·         Alcoholic Ketoacidosis

·         Appendicitis

·         Urinary Tract Infection (UTI) in Females

·         Lactic Acidosis

·         Metabolic Acidosis

·         Salicylate Toxicity

 

·         Septic Shock

Treatment

If you are diagnosed with DKA, vigilant management is required, which is performed in the hospital. The goals of treatment include;

·         Correction of blood glucose levels using IV insulin,

·         Correction of hydration status by giving IV fluids

·         Replenishing electrolytes, especially potassium

·         Correcting acid-base status of the body

 

·         Treating the underlying cause

Prognosis

The outcomes are excellent when the DKA is diagnosed on time and treated properly. If the patient presents with a deep coma, decreased body temperature, decreased urine output, the prognosis is poor. Also, a severe illness in older age patients has a poor prognosis.

Prevention

If you have diabetes mellitus, you must be prepared to prevent the chances of DKA. You must have complete knowledge about controlling your diabetes and reacting or seeking help if something goes wrong. Make sure you take care of the following points;

·         Keep a check on your blood sugar levels, particularly if you are sick

·         Take your medicines regularly and avoid missing doses

·         Try to keep your sugar in the normal range and avoid taking sugary foods that can derange your blood sugar levels

·         Don’t forget to ask your doctor about adjusting your insulin doses in case you fall sick

·         If you are suffering from infection or physical or mental stress, you should know how to adjust your insulin dose if the sugar levels are uncontrolled

 

·         You should immediately seek help if the levels of ketones are high in your home test kit results.

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