Diabetic ketoacidosis is a severe complication
Author: Dr Sorin Ioacara | Last update: 31 August 2020
Diabetic ketoacidosis is a severe acute complication of type 1 diabetes. Sometimes it can also occur in type 2 diabetes with a high insulin deficiency and a major precipitating factor (e.g. a severe viral or bacterial infection). Decreasing insulin availability below a certain critical threshold will unlock a particular pathway for fatty acids metabolism in the liver. This new pathway leads to their transformation into ketone bodies. Consequently, the accumulation of ketone bodies eventually heads to diabetic ketoacidosis. Hence, ketoacidosis is mostly a significant defect in lipid metabolism and not glucose metabolism.
Frequency of diabetic ketoacidosis
Type 1 diabetes begins in more than 50% of cases with ketoacidosis. The percentage rises to 70% for children with slightly lower access to education or medical care. Besides, children aged less than three years almost always have a degree of ketoacidosis at onset. However, after the clinical diabetes onset, the risk of developing diabetic ketoacidosis decreases significantly. Still, even in stages 3 and 4 of type 1 diabetes, the risk of diabetic ketoacidosis is never absent.
If we follow 1000 patients with type 1 diabetes, we will find the appearance of approximately 50 episodes of ketoacidosis every year. However, these episodes occur in only about 30 patients. The explanation is that some patients have repeated episodes of ketoacidosis in one year. Indeed, diabetic ketoacidosis tends to occur primarily in patients who have had such events in the past.
The top ten risk factors for diabetic ketoacidosis are:
- Complete or partial discontinuation of insulin therapy
- The onset of type 1 diabetes
- Food poisoning with diarrhoea and vomiting
- Any significant viral or bacterial infection
- Insufficiently supervised child
- Adolescence, especially in girls
- Alcohol intoxication
- Major cardiovascular events (e.g. myocardial infarction)
- Lack of access to continuous blood glucose monitoring sensors
- Lack of access to insulin pumps with the possibility of “close-loop”
Symptoms of diabetic ketoacidosis
The symptoms of diabetic ketoacidosis appear gradually over several hours. Their evolution depends very much on the way the patient hydrates himself during this period. As an example, the use of sweet juices at the onset of type 1 diabetes quickly aggravates the situation. However, intense hydration with plain water can significantly slow down the rate of ketoacidosis. In this way, it is often possible to intervene therapeutically at home and thus avoid hospitalization.
The main symptoms of diabetic ketoacidosis are:
- Increased heart rate
- Lack of air
- Nausea and vomiting
- Abdominal pain
- Confusion, drowsiness
- Loss of consciousness, coma
Dehydration and increased heart rate
The main symptom of diabetic ketoacidosis is dehydration. Consequently, the mouth and lips are dry. Also, the tongue becomes loaded with whitish secretions. The fold of the skin on the abdomen persists a little longer when you release it.
The affected patient feels a fatigue that does not go away through resting. So, the dehydrated child does not feel like playing and runs less. Severe dehydration in the child may be associated with tear-free crying from sunken eyes.
The second prominent symptom is increased heart rate (tachycardia). The heart beats faster to maintain the required blood flow when its total volume has decreased. Therefore, the pulse of a dehydrated child is often over 100 beats per minute.
Shortness of breath, nausea and vomiting
As the severity of ketoacidosis increases, so will the lack of air. So, the patient takes a deep breath and breathes more often than usual. Therefore, when the patient with diabetic ketoacidosis is lying on his back, you can see a broad range of movements of the sternum and rib cage with each breath. This type of breathing has been called Kussmaul breathing. Also, the exhaled air has a slight odour of acetone or green apples.
Nausea and vomiting are alarming symptoms of the need for hospitalization to resolve diabetic ketoacidosis. Loss of fluid and minerals from vomiting will exacerbate the patient’s dehydration. Anti vomiting medication does not affect the nausea. Moreover, they don’t work whether administered orally or intravenously.
Abdominal pain, confusion, drowsiness and coma
Diffuse pain may appear in the abdominal wall, which accentuates when pressing the belly. This creates the impression of a medical problem of the digestive tract. In the past, appendicitis operations were sometimes unnecessarily performed as a result of a false “surgical abdomen”. This “stomach” pain does not wean following the administration of antacids or “ulcer” drugs.
Moderate ketoacidosis can interfere with the patient’s rational thinking. The answers come harder in a conversation, and the sentences tend to be shorter. The onset of extreme fatigue with marked drowsiness indicates severe diabetic ketoacidosis.
The patient who has lost consciousness is in a critical, life-threatening situation. He must be transported to the hospital as soon as possible to save his life.
Diagnosis of diabetic ketoacidosis
The association of the following three criteria makes the diagnosis of diabetic ketoacidosis: a. high blood glucose, b. blood acidosis, and c. the accumulation of ketone bodies. Usually, the patient gets this diagnosis in the hospital, based on the determination of venous blood glucose, ASTRUP parameters (e.g. pH, bicarbonate) and urinary ketone bodies. Here, the doctor should use ketone bodies determined from blood if the local lab can measure them. However, the patient can conveniently use coloured strips to measure urinary ketone bodies at home. Therefore, you can already suspect the diagnosis at home, based on the symptoms described above and the presence of ketone bodies in the urine.
High blood glucose
Hyperglycaemia in the context of ketoacidosis diagnosis means any blood glucose value greater than 250 mg/dl (13.9 mmol/l). In general, blood glucose levels recorded in diabetic ketoacidosis are over 600 mg/dl (33.3 mmol/l). Hence, measuring them with a glucose meter will display the message “HI”. This message is an abbreviation of the term “HIGH”. The significance of the ‘HI’ message on the glucose meter is that the blood glucose value is above the upper limit that the device can measure. Most often, this upper limit is 600 mg/dl (33.3 mmol/l).
Lower blood glucose values of 250-600 mg/dl (13.9-33.3 mmol/l) may occur in conditions of diabetic ketoacidosis combined with a severe restriction of carbohydrate intake. Also, proper hydration can make an additional contribution to the appearance of this situation.
In recent years, a new diabetic ketoacidosis entity has emerged. In this case, the blood glucose value is generally below 250 mg/dl (13.9 mmol/l). The name assigned for this disorder is euglycemic ketoacidosis. This form of ketoacidosis may sometimes appear in association with the use of an SGLT2 inhibitor drug. An SGLT2 inhibitor is a diabetic drug that lowers your blood sugar by allowing some glucose to pass into the urine. However, this medication was initially designed for type 2, not type 1 diabetes.
Acidosis is a disease in which the blood is more acidic than it should be. The term metabolic shows that the leading cause for which the blood has a pH below the lower limit of normal is the decrease in the concentration of bicarbonate. Usually, the blood concentration of bicarbonate is 22 mmol/l. In diabetic ketoacidosis, it drops below 18 mmol/l.
A liquid mixture (a solution), such as blood, can be acidic, neutral or basic. Acid means that the solution has a pH below 7, neutral corresponds to the figure 7, and basic for any pH value above 7. The normal pH of the blood is 7.36-7.44. Consequently, the blood is slightly basic because it contains a significant amount of baking soda (identical to that used for making cakes).
In diabetic ketoacidosis, the pH of the blood drops below 7.3. Usually, it is most often between 7.1 and 7.3. In other words, the blood of the patient with diabetic ketoacidosis continues to be slightly basic. Acidosis does not mean that the blood is acidic. This term refers to the simple fact that the blood is more acidic than it should be. Acidosis is that disease that tends to drop the pH below the lower limit of normal. It doesn’t matter that the pH is still in the basic range.
Ketone bodies are quite strong acids. A solution containing only water and ketone bodies would have a pH below 5. A mixture of this solution and blood leads to a pH below 7.3, if there are sufficient ketone bodies.
When an acid (ketone body) meets a base (bicarbonate) a reaction occurs through which the two neutralize each other. The concentration of ketone bodies in the blood of a patient with diabetic ketoacidosis is over 5 mmol/l. At this concentration, a significant amount of bicarbonate is continuously consumed. Consequently, the blood concentration of bicarbonate and implicitly the pH value will decrease.
A higher value of ketone bodies in the blood is associated with a parallel increased concentration in the urine. Testing urine with a coloured strip will substantiate the presence of ketone bodies in the urine. In diabetic ketoacidosis, urinary ketone bodies will have at least average values on the colour test (≥2+). However, the results usually indicate large or vast amounts of urinary ketones.
Prevention of ketoacidosis
The best treatment for diabetic ketoacidosis is its prevention. So, the first thing to do in this regard is to know very well what are the risk factors for ketoacidosis (see above). You may overlook some things precisely because they are too simple. Later, at the hospital, patients or their parents admit that they could prevent hospitalization, often saying “You’re right, I didn’t think…” Therefore, a good education in this regard can help you stay healthy at home and avoid hospitalization.
Do not skip insulin doses
The best prevention of diabetic ketoacidosis is to take all the doses of insulin the body needs. Omission of insulin doses is the most critical risk factor for the subsequent onset of ketoacidosis in a patient with type 1 diabetes.
If you forget to take your basal insulin dose, you should take it as soon as you remember. In the following days, you can do this administration two hours earlier each day. Thus, you may gradually go back to your usual time. Administer prandial insulin doses before the meal whenever possible. If the situation requires it, administer the insulin dose as soon as possible after the meal. Consequently, you decrease the chances of forgetting its administration.
If your insulin has run out and it takes a long time to get a free prescription, go to the pharmacy urgently and buy the insulin you need. In this situation, it is not worth thinking about waiting because you were entitled to it for free. To avoid such situations in the future, make sure you have a stockpile of insulin for emergencies.
Insulin doesn’t seem to work anymore
Sometimes the body uses insulin inefficiently. This situation is equivalent to skipping insulin doses. First, check the shelf life of insulin. Second, make sure that the insulin has been stored properly.
Replace the catheter and reservoir if you use an insulin pump, and consider taking bolus using a pen. Do not give insulin in a lipohypertrophy area (fat accumulation). Remember that most often, insulin works, but the need is unexpectedly much higher than anticipated.
Check the presence of ketone bodies in the urine, using coloured strips whenever blood glucose persists above 300 mg/dl (16.7 mmol/l) for three hours. Use capillary blood testing if you have access to a glucometer and tests that can determine ketone bodies in this way.
Learn about the symptoms of type 1 diabetes
Knowing the signs and symptoms of type 1 diabetes is essential for its timely discovery. The onset of stage 3 of type 1 diabetes with diabetic ketoacidosis is almost always preventable through proper education. This education is essential for those already in stage 1 or 2 of the disease (still asymptomatic). Given the rather high and growing risk of type 1 diabetes in the general population, I believe that a public “mass” education should be made on this subject.
Pay attention to digestive intolerance
Digestive intolerance manifests by vomiting and diarrhoea. The causes can be multiple. Treat gastrointestinal intolerance carefully by consulting your doctor. Based on your medical recommendation, you may use local antiseptics or antibiotics. Rehydration salts often help in this process. Remember that insulin absorption from under the skin is weaker under severe dehydration.
Besides, to prevent diabetic ketoacidosis, remember that basal insulin has nothing to do with what you eat. You must continue to use basal insulin despite not eating anything. Basal insulin deals with the sugar produced by your liver and kidneys. It does not deal with carbohydrates in the diet. Change the dose continuously, generally depending on your morning blood sugar.
In the absence of food, there is a tendency to stop taking any insulin. Continue to take small doses of mealtime insulin, even if you do not eat. The aim is to correct any rising trend of your blood sugar above 150 mg/dl (8.3 mmol/l).
Adjust insulin doses in case of infection
Most major infections will increase your daily insulin requirement. It doesn’t matter if they are viral or bacterial. Treat the cause of the disease with the utmost care. Also, provide comprehensive symptomatic treatment. When treating the symptomatic infection, do not forget to hydrate yourself.
Anticipate a 25% increase in basal insulin requirements and a 50-100% increase in prandial insulin. Check your blood sugar every 1-2 hours as long as you feel sick. Small and repeated doses of prandial insulin every 2-3 hours are better than larger ones done at intervals of 4-6 hours.
Make sure you have everything you need to correct any hypoglycaemia that may result from overlapping meal doses. This is quite difficult during the illness. The chances of hypoglycaemia increase rapidly when the source of the infection disappears.
Supervise the children carefully
The young child and the preschooler cannot make the necessary decisions alone. They are entirely dependent on adult support. If this support is precarious or through less involved intermediaries, it can sometimes lead to significant hyperglycemia. Persistence of blood glucose above 300 mg/dl (16.7 mmol/l) for more than three hours is an adverse prognostic factor for the subsequent chances of ketoacidosis.
As the child enters high school, he or she will gradually take on more and more treatment-related responsibilities. No matter how much you trust your child, periodically check every aspect of diabetes care at school. Of great importance here is the support offered by the school, both as storage spaces dedicated to the child, and as human resources capable of helping the child in need.
Take great care of teenagers
The insulin requirements of adolescents are much higher compared to the previous period. Often, this need is even higher than the subsequent need in adulthood. Limiting the amount of insulin administered because of the perception that it is not good to take so much insulin is entirely wrong and dangerous. The teen needs to take as much insulin as he or she needs to have the best metabolic control.
Everybody should encourage and help adolescents with type 1 diabetes in their efforts to integrate with other adolescents without diabetes. Family conflicts are inevitable, but the way you go through them can sometimes increase the risk of diabetic ketoacidosis. The revolt of a teenager after a significant conflictual situation can leave him exposed in the face of this danger. Discuss in advance, especially with girls, the importance of paying full attention to diabetes control no matter how much anger you feel during future quarrels.
Depression is much more common than you think among teens with type 1 diabetes. Promptly intervene and talk openly with the retiring teenagers. Do so, especially if they no longer like their preferred things and activities.
Consumption of banned substances (e.g. inhaler) dramatically decreases the interest of the adolescent in the care of diabetes. They will reduce the number of daily fingerstick glycemia done and actively used. Also, they will increase the number of missed insulin doses. This combination is the perfect recipe for ketoacidosis appearing at the slightest common cold.
Avoid excess alcohol consumption
Alcohol consumption itself increases the risk of hypoglycemia, not hyperglycemia. However, when consumed in sweet drinks (cocktails), the situation can change radically. Cocktails can contain significant amounts of carbohydrates not accounted for with insulin.
Besides, alcohol intoxication seriously interferes with the ability of the patient with type 1 diabetes to take care of himself. Loss of consciousness can occur as a simple drowsiness, not necessarily through alcoholic coma. The patient who has fallen asleep might no longer take his evening basal dose of insulin.
Carbohydrates from previously consumed cocktails may, in this case, lead to the onset of diabetic ketoacidosis in the early hours of the morning, before waking up. Also, alcohol has an effect of stimulating the release of fatty acids from stores and their transformation in the liver into ketone bodies.
Tell your doctor about insulin therapy when you get into a hospital
When hospitalized for pneumonia or a major cardiovascular event, you should warn the doctor about the presence of type 1 diabetes. Sometimes, the primary condition for which the patient gets into the hospital is very noisy, and the simultaneous presence of mild ketoacidosis is not observed. Untreated, the accompanying ketoacidosis can quickly become moderate or severe.
Use continuous glucose monitoring sensors
For a proper prevention of diabetic ketoacidosis, the patient with type 1 diabetes needs to take a blood glucose every two hours. The frequency may increase to one per hour in the presence of significant hyperglycemia or malaise. An elegant way to access these blood glucose levels is to use a continuous glucose monitoring sensor. This way, you will have access to a blood glucose estimate every five minutes.
Most continuous blood glucose monitoring sensors offer the ability to track recorded values remotely. This remote tracking is vital for the parent when away from his child. The main reason for using too small insulin doses to correct a high blood glucose is the fear of hypoglycaemia.
The use of continuous glucose monitoring sensors offer the chance to capture the trend of blood sugar not only its instantaneous value. So, you have enough time to take the necessary measures to prevent the occurrence of hypoglycemia and then to treat it. Consequently, these sensors partially eliminates the fear of hypoglycemia.
Use closed-loop insulin pumps
Some insulin pump models can gradually increase or decrease their insulin flow based on the information provided by the blood glucose sensor. These systems are called closed-loops. Where the patient hesitates or forgets to intervene, the insulin pump will do it for him. Diabetic ketoacidosis will have a significantly lower risk of occurrence due to the use of closed-loop systems.
The closed-loop insulin pumps minimize the risk of hypoglycaemia associated with increased intensity of insulin treatment. They do that by reducing or discontinuing insulin when blood glucose might become dangerously low.
Treatment of incipient ketoacidosis at home
Diabetic ketoacidosis accompanied by vomiting or significant dehydration that does not allow the patient to stand and walk alone should be treated in the hospital. A ketoacidosis diagnosed quickly, in the early stages, in which the patient is active and can drink water without problems can be initially treated at home, under remote medical supervision. The discussion with your doctor about your mild ketoacidosis might include some of the following aspects. Regardless of the suggestions below, listen precisely to what your doctor or rescue staff tells you.
Hydration and insulin therapy
In diabetic ketoacidosis, the central component of treatment is proper hydration. Adolescents should drink 1-2 litres of water per hour and proportionally less in a younger child. In other words, you should choose the most substantial amount of water the child can consume. Also, using rehydration salts helps.
Insulin treatment consists of repeated boluses of fast-acting insulin analogues (aspart, fiasp or lispro). You might consider a bolus of 0.3 U/Kg body if the initial glycemia is >600 mg/dl (33.3 mmol/l). This initial bolus might be around 0.15 U/Kg body if the initial blood glucose is <600 mg/dl (33.3 mmol/l).
Subsequently, after one hour, you may consider a dose of 0.05 U/Kg body weight. You may then repeat this dose every one hour. The goal is to lower the blood sugar with a rate of 50-75 mg/dl (2.8-4.2 mmol/l) per hour.
You should measure the blood glucose before each insulin administration. If the blood sugar drops by more than 75 mg/dl (4.2 mmol/l) in the last hour, you may reduce the current bolus by half. If the blood sugar has dropped less than 50 mg/dl (2.8 mmol/l), you may increase the present bolus to 0.075-0.1 U/Kg body weight.
Potassium and magnesium supplementation
The body of a patient with diabetic ketoacidosis has a very high deficiency of potassium and magnesium. It would be best if you consider administering standard combined potassium and magnesium tablets by mouth.
For a teenager, the requirement would be one tablet every two hours for six hours (four tablets). If you have 7.4% KCL solution, you may consider using 0.1 ml/Kg body weight, dissolved in 250 ml of water (one cup), administered orally once every hour, for six hours. Always discuss the treatment with your doctor!
Contact and listen to your doctor’s advice!
All these suggestions do not legally represent medical indications for treatment! I cannot recommend that you should apply them directly without your doctor’s approval. They are, as I mentioned from the beginning, a suggestion about the discussion you may have with your doctor to solve the diabetic ketoacidosis.
For a correct and safe treatment, contact your doctor or go to the nearest hospital urgently.
Complications of diabetic ketoacidosis
Diabetic ketoacidosis is a formidable complication of type 1 diabetes, which in turn can lead to severe complications. A significant drop in blood potassium levels during the treatment is the leading cause of mortality in diabetic ketoacidosis uncomplicated with a heart attack or stroke. That is why it is vital to supplement the potassium intake throughout the treatment.
The top 10 complications of diabetic ketoacidosis are:
- Decreased blood potassium
- Cerebral oedema
- Acute renal failure
- Hypoglycaemia (during treatment)
- Acute respiratory distress syndrome (ARDS)
- Reduced levels of blood phosphate
- Hyperchloremic acidosis
- Intestinal necrosis