Management of diabetic ketoacidosis

Dr Louise Johnson informs on what diabetic ketoacidosis is, the signs and how to manage it.

What is diabetic ketoacidosis?

Diabetic ketoacidosis (DKA) is an acute life-threatening complication of diabetes. DKA happens when your blood glucose is very high and acidic substances, called ketones, build up to dangerous levels in your body. It’s characterised by high glucose and ketonuria (ketones on dipstick in urine) and ketoacidosis.

The cause is due to decreased amount of insulin and too much glucose. The metabolism shifts from the carbohydrate metabolism to a starvation state where the fat metabolism is used.

 Signs and symptoms

• General weakness, tiredness
• Polyuria (passing a large amount of urine) and polydipsia (excessive thirst)
• Nausea and vomiting
• Abdominal pain
• Decreased appetite
• Rapid weight loss in a new Type 1 diabetes patient
• Altered consciousness, disorientation and confusion
• Decreased sweating with dry skin
• Dehydration
• Laboured breathing, called Kussmaul breathing
• Apple smell on the breath
• Dizziness due to low blood pressure and palpitations
• Glucose more than 20 mmol/L and ketones on some glucose machines (if possible) and in urine as detected by a urine dipstick

Causes of DKA

• Infection, especially bladder infections, lung infection, feet, tooth or other
• Inflammation i.e. arthritis
• Heart attack characterised by chest pain
• Not taking insulin or enough insulin
• Insulin not delivered due to pump obstruction or insulin pump failure
• Trauma that can be either physical or emotional. The death of a pet is enough emotional stress to cause this.

The incidence of DKA is mainly in Type 1 diabetes but can also be seen in Type 2 diabetes that are on insulin and develop a bad infection.

In Type 1 diabetes it’s more common in young children and adolescents due to growth hormone and sex hormones that increases. It’s also seen in adolescents with psychological stress where insulin is not taken correctly or omitted on purpose.

Management of DKA

The most important factor is to test blood glucose when any of the signs are present. Nausea and abdominal pain are early signs that can be used to prevent hospitalisation.

If you are showing any signs, you should check your blood glucose and give a short-acting insulin as a correction to bring the glucose down below 10 mmol/L.

Drink clear water in an amount of 100ml/kg. In a person weighing 60kg that would be six litres. Drink the water slowly and check glucose every hour. About 1 litre fluid per hour.

Should there be excessive nausea, an anti-emiticum can be used for nausea, such as Valoid suppository.

If there are no signs of infection and the glucose is responding to the treatment, you can stay at home. In the case where the glucose is not responding and vomiting or confusion appears, you will need to be admitted to a hospital for intravenous insulin.

Prognosis

The overall mortality rate for DKA is 0,2 to 2% with persons with coma having the worse prognosis.

In properly treated patients, the prognosis is excellent. Before the discovery of insulin, in 1922, the mortality was 100%. Over the last three decades, the mortality rates from DKA have markedly decreased from 7,96% to 0,67%¹.

References:

1. Lin SF, LIN JD et. al. “ Diabetic ketoacidosis: comparison of patient characteristics, clinical presentations and outcomes today and 20 years ago.” Chaung Gung Med J 2005, Jan 28(1):24-30