Sunday, September 24, 2023

Diabetic Ketoacidosis: What Every Diabetic Should Know

You should learn to detect the signs and symptoms of diabetic ketoacidosis, which is a medical emergency.

Diabetic Ketoacidosis (DKA) is a medical emergency—if you suspect that you or a family member has DKA, contact a medical facility immediately, instead of trying to manage it yourself.

In this article, I will discuss how DKA develops, what its signs and symptoms are, why it is dangerous, and what your options are. The idea is that every family member of a diabetic person should know about this life-threatening possibility and when to seek help. Do not use this information to treat yourself or your family members for DKA.

How Does Diabetic Ketoacidosis Develop?

If you have high blood glucose or hyperglycaemia, under certain conditions, you can develop ketoacidosis.

Insulin is needed for your body cells to use blood glucose. But, if there is a lack of insulin in the body, the cells cannot use glucose, raising blood glucose levels. Such an energy-starved body starts breaking down fats to produce chemicals called ketones. These are used by your cells as an alternate source of energy.

When your blood has high levels of ketones, your body is said to be in ketosis. You may have heard this word in relation to weight-loss or fat-loss strategies. People knowingly reduce their carbohydrate intake to put their bodies into the ketosis state, thereby reducing body fat.

A diet very low in carbohydrates and high in fats is called the ‘keto’ or ketogenic diet. Such a diet has four grams of fats for every gram of carbohydrates and proteins.

Ketosis is a normal and safe response of the body to a lack of carbohydrates.

However, ketones are acidic and if their levels rise too much in the blood, it can become acidic, too. This is called ketoacidosis and is a medical emergency.

If too many ketones are formed in the body, some are eliminated in the urine and can be detected with a dipstick ‘spot’ test using a ketone test kit available in the chemist shops. If your urine has high levels of ketones, you can assume you have DKA and start the treatment.

Ketosis versus Ketoacidosis

Ketosis happens with a lack of carbohydrates in the body, while ketoacidosis is mainly due to the absence of insulin.

In ketosis, the blood glucose will be low, while in ketoacidosis, the blood glucose levels do not matter. For example, some people get ketoacidosis even when the blood glucose is normal, which is called Euglycaemic Diabetic Ketoacidosis. Eu– means good; –glycaemic refers to blood glucose.

Low carbohydrate intake can rarely cause ketoacidosis. But the absence of insulin makes your body think of starvation, making it produce ketones in copious amounts leading to ketoacidosis.

Note that:

  • High blood glucose does not necessarily cause DKA. Both of them can be caused by a shortage of insulin in the body and are seen together.
  • Since the body does not produce insulin in type 1 diabetes, ketoacidosis can often develop in type 1 diabetes.
  • Some people with type 2 diabetes cannot produce insulin in their bodies. Such people also may suffer from an occasional DKA.

Causes of Diabetic Ketoacidosis

Some causes of DKA are:

  1. Missing insulin injection, wrong insulin dose, spoiled insulin, or faulty insulin pump. Sometimes, DKA is the first time a person with undiagnosed type 1 diabetes learns about his condition.
  2. Illness, which is stressful on the body and causes it to increase its production of stress hormones, adrenaline and cortisol, which reduce insulin action. A sick person may not eat or drink properly making blood glucose control difficult.
  3. Infections such as pneumonia and infections of the skin and urinary tract also trigger stress hormone release.
  4. Accidents, surgery, or emotional trauma can be stressful and cause DKA as above.
  5. Alcohol and drug abuse may lead to missed food or insulin injections. Alcohol increases cortisol production.
  6. Some medicines such as corticosteroids and second-generation antipsychotic drugs can cause DKA. Diabetes medicines called SGLT-2 inhibitors can also cause DKA.
  7. Inflamed pancreas or pancreatitis can reduce insulin production and lead to DKA.
  8. A heart attack or stroke in a person with diabetes can cause DKA.
  9. Pregnant women who are diabetic have a 0.5%–3% risk of developing DKA because as the pregnancy progresses, they need more insulin and may develop increased insulin resistance, making insulin less effective.

Signs and Symptoms of Diabetic Ketoacidosis

In the early stages, you feel thirsty, drink more water, and urinate much more frequently.

As the symptoms worsen, you:

  • Feel: Tired, sleepy, confused, or sick.
  • Have: Blurry vision, fast and deep (not shallow) breathing, flushed face, nausea, vomiting, dehydration, abdominal pain, muscle stiffness, aches, dry skin, and dry mouth.

You can fall into a coma, which is extremely dangerous if you are alone.

Acetone On Your Breath

One interesting way to tell if you have ketoacidosis (or ketosis) is if you smell a sweet, fruity fragrance. Some of you would recognise it as the smell of nail polish remover. Here is the science behind it:

When fats are broken down in your liver, three types of ketones are formed. Two of them are used for energy production; the third—acetone—has a tendency to evaporate and gets expelled from the lungs, which your nose can smell. Acetone is used in nail paint remover and has a sweetish smell.

If you are a marathon runner, you have heard of the phrase ‘Hitting the Wall’. This is roughly the thirty-kilometre point of the 42-km race, where your body nearly exhausts its carbohydrate (glucose and glycogen) reserves and has to switch to fat-burning (ketones) for energy production.

Since energy generation from fats needs thirty per cent more oxygen compared to that by carbohydrates, your speed reduces by thirty per cent all of a sudden. Your run feels like a sudden crawl as if you have hit a wall. In such situations, you start smelling of nail polish remover in the middle of the road, a weird experience that I have been through a couple of times in my marathons.

Management of Diabetic Ketoacidosis

The chances of death in DKA are 1% to 5%. So seek a hospital setup for assistance immediately.

The typical treatment will be (leave this to the discretion of the doctors treating you):

  • Insulin, which will help your body to use blood glucose and cause your liver to stop further production of ketones.
  • Fluids, which are lost due to frequent urination. Besides reducing dehydration, they will also dilute excess blood glucose.
  • Electrolytes, which are lost in the urine in DKA. When blood glucose is normal, your kidneys reabsorb and prevent glucose from getting excreted in urine. But in hyperglycaemia, they cannot reabsorb glucose, causing it to come in urine, the presence of which pulls more water along with electrolytes into the urine (through a process called osmotic diuresis).
  • Antibiotics and other medicines to treat illnesses that may have caused your DKA.

Since these are difficult to administer without a trained person to help you, DKA should not be managed at home.

Prevention of Diabetic Ketoacidosis

Common sense is the most important tool to prevent DKA.

  • Take your food, medicines, and insulin on time as prescribed.
  • Check your blood glucose at least three times a day, or wear a Continuous Glucose Monitor.
  • Check your urine for ketone levels, if you have an illness, infection, or physical or emotional stress.
  • If you detect low levels of ketones in the urine, increase your insulin as instructed by your doctor.
  • If your urine has high levels of ketones, seek medical help immediately.
  • Keep emergency contact numbers handy.

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First Published on: 27th August 2023
Image Credit: jcomp on Freepik


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