Definition of Diabetic Ketoacidosis (DKA)
Diabetic ketoacidosis (DKA) is a serious medical condition that can occur in people with diabetes mellitus. It is characterised by high blood sugar levels, elevated ketone levels, and metabolic acidosis and is a medical emergency. DKA is most commonly seen in patients with type 1 diabetes, but it can also occur in patients with type 2 diabetes.
Insulin deficiency is the primary cause of DKA, as the body cannot properly use glucose for energy, and instead breaks down fat for fuel. This process leads to the production of ketones, which can build up in the blood and cause a range of symptoms. DKA requires immediate medical attention, as it can lead to serious complications, including cerebral oedema and in rare cases, even death.
Causes of Diabetic Ketoacidosis
There are several factors that can contribute to the development of DKA.
One common cause is illness, such as an infection or flu. When you’re sick, your body releases hormones that can raise blood sugar levels, and if you’re not able to eat or keep food down, it can lead to dehydration and a lack of insulin in your body.
Missed insulin doses can also trigger DKA. Insulin is a hormone that helps regulate blood glucose concentrations, and without enough insulin, your body can’t use glucose for energy, leading to the production of ketones.
Other factors that can contribute to DKA include experiencing a heart attack or stroke, which can disrupt blood flow and affect insulin levels. In these cases, it’s important to seek immediate medical attention.
It’s worth noting that high ketone levels can be an early sign of DKA and should be taken seriously. If you have diabetes and notice symptoms such as excessive thirst, frequent urination, abdominal pain, or a fruity breath odour, it’s important to check your ketone levels and seek medical help if they are elevated.
Diabetic Ketoacidosis Symptoms
It is important to be aware of the symptoms of DKA in order to seek prompt medical attention.
The first sign of DKA is usually hyperglycaemia, which refers to abnormally high blood sugar levels. This can lead to:
- Increased thirst
- Frequent urination
- Feeling extremely tired
Other symptoms to look out for include:
- Nausea
- Vomiting
- Abdominal pain
- Deep and laboured breathing
- Breath that has a pear drops smell (sometimes described as acetone)
If left untreated, DKA can progress and become life-threatening. One of the most serious complications of DKA is acute cerebral oedema, which refers to swelling of the brain. This can lead to neurological symptoms including changes in behaviour, confusion, seizures, or even loss of consciousness (sometimes known as a diabetic coma).
Investigations for Diabetic Ketoacidosis
In order to diagnose and manage DKA effectively, various investigations may be carried out. These investigations aim to assess blood glucose concentrations, ketone levels, electrolyte imbalances, and any underlying causes of DKA.
The Arterial Blood Gas (ABG)
The Arterial Blood Gas (ABG) is a crucial test used in diagnosing and managing diabetic ketoacidosis. It measures the acidity, oxygen, and carbon dioxide levels in the blood, providing valuable information about the patient’s respiratory and metabolic status.
The ABG helps in assessing the severity of DKA by measuring the pH level, which indicates the blood’s acidity. A low pH value suggests acidosis, which is a key feature of DKA. Additionally, the ABG measures the levels of oxygen and carbon dioxide in the blood, giving insight into the respiratory function. Acidosis in the blood could be due to the presence of a lot of ketones, which is necessary for the diagnosis of DKA, but may also be worsened by high levels of lactate in the blood. This is known as lactic acidosis, and in DKA this can be a sign that a patient has severe DKA. Lactate is usually one of the values tested for an ABG.
Monitoring the ABG throughout the treatment of DKA is essential. It helps healthcare professionals assess the response to treatment and make necessary adjustments. Adjusting insulin doses, administering fluids, and correcting electrolyte imbalances can all be guided by the information obtained from the ABG.
An ABG is usually taken from the wrist using a needle. Blood has to be taken from the artery, and this can be more uncomfortable than a normal blood test. In diabetic ketoacidosis, more often than not it is possible to do a Venous Blood Gas (VBG) instead of an ABG. This is because your doctor doesn’t necessarily need to test your lung function unless this is a specific concern due to your individual circumstances. A VBG can be taken in the normal way, as a part of your other blood tests. It can diagnose diabetic ketoacidosis just as accurately as an ABG.
Ketones
Ketones play an important role in diagnosing and managing diabetic ketoacidosis. When the body doesn’t have enough insulin to convert glucose into energy for cells, it starts breaking down fat for fuel. This process produces ketones as a by-product.
There are several ways to test for ketones. The most common method is a urine test, where you collect a small sample in a container and use a test strip to measure the ketone levels. Another method is a blood test, where a healthcare professional takes a small amount of blood and measures the ketone levels using a special meter (similar to how blood sugars are tested).
Regular testing for ketones is important, especially during illness or when blood sugar levels are high. This helps to identify the early signs of DKA and allows prompt treatment to prevent complications.
The normal range for ketones in the blood is less than 0.6 mmol/L. If the levels exceed this range, it may indicate that DKA is developing, and immediate medical attention is required.
If you have diabetes, it’s essential to familiarise yourself with the testing procedures for ketones and perform them as advised by your healthcare provider. Keeping an eye on your ketone levels can help you manage your condition effectively and prevent DKA episodes.
Look for a Cause
When a person experiences diabetic ketoacidosis, it is important to investigate the underlying cause. The aim is to identify any infections or other factors that may have contributed to the development of this serious condition.
One of the first steps is to assess the possibility of underlying infections. In some cases, infections such as urinary tract infections or respiratory tract infections can trigger DKA. If an infection is suspected, healthcare professionals may obtain relevant cultures, such as urine or blood samples, to determine the specific pathogens (bacteria) involved. If appropriate, antibiotics may be prescribed based on the results of these cultures.
However, it is important to note that infective precipitants for DKA are actually quite uncommon. In many cases, the primary cause is related to insulin doses. It is crucial to assess the insulin doses of individuals with known type 1 diabetes, especially in children. Omission or significant reduction in insulin doses can lead to the development of DKA.
Diabetic Ketoacidosis Treatment
The mainstay of DKA treatment is an intravenous infusion of insulin, which helps to lower blood sugar levels and normalise ketone production. In addition to insulin, fluid replacement is also essential to correct dehydration and electrolyte imbalances. Patients are usually admitted to the hospital for close monitoring and intensive care, as DKA can lead to serious complications such as cerebral oedema and myocardial infarction. Other aspects of DKA treatment may include addressing the underlying causes, managing any infections, and addressing any other medical issues. The aim of treatment is to stabilise the patient’s condition, restore normal blood glucose and ketone levels, and prevent further complications.
Initial Assessment & Treatment Priorities in the Emergency Department
In the Emergency Department, the initial assessment and treatment priorities for diabetic ketoacidosis are crucial in managing this potentially life-threatening condition.
A thorough evaluation is essential, starting with assessing vital signs like blood pressure, heart rate, and respiratory rate. Blood glucose levels are also measured to determine the severity of the DKA episode.
Obtaining a detailed medical history and performing a physical examination helps to identify any underlying causes or complications of DKA. Laboratory tests such as blood gas analysis, full blood count, and kidney function tests aid in assessing the patient’s condition.
Treatment priorities focus on restoring fluid balance and correcting electrolyte imbalances. Intravenous fluid resuscitation (the process of giving fluids quickly though an intravenous infusion) is initiated early on. Insulin therapy is also promptly started to address the underlying insulin deficiency and decrease blood glucose levels. Careful monitoring of the patient’s response to treatment, including blood glucose, ketone levels, and electrolytes, is essential to ensure a successful outcome.
In very severe cases of DKA, it may be necessary for patients to be treated on the intensive care unit. This is so that patients can have very close monitoring, and more invasive treatments that cannot be given on normal wards.
Insulin Therapy & Fluid Replacement
Insulin therapy and fluid replacement are crucial components of the treatment for diabetic ketoacidosis. Insulin therapy involves stopping a patient’s regular insulin doses and the administration of continuous intravenous insulin to correct the underlying deficiency. A patient’s long-acting regular insulin doses should be continued even whilst the infusion is running, and only short-acting regular insulin doses should be stopped.
In severe cases of DKA, this is typically achieved through continuous intravenous insulin infusion (a drip that goes through a line left in the vein). The dosage of insulin is carefully adjusted based on the patient’s blood glucose levels, aiming to gradually decrease them towards normal levels. The insulin infusion rate will initially be set based on a patient’s weight, and then adjusted according to response.
Fluid replacement is another important aspect of DKA treatment. Intravenous fluid therapy, usually in the form of normal saline, are administered to restore fluid balance and correct electrolyte imbalances. This helps to dilute the excess ketones and glucose in the blood.
During treatment, it is vital to monitor blood glucose levels frequently and adjust the insulin infusion rate accordingly. This monitoring ensures that blood glucose levels are decreasing at an appropriate rate without dropping too rapidly, which can lead to complications. It also allows healthcare professionals to determine if the insulin dosage needs to be adjusted.
Overall, the combination of insulin therapy and fluid replacement plays a crucial role in resolving DKA episodes. Regular monitoring and adjustment of treatment are necessary to ensure the best possible outcomes for patients.
Electrolyte Monitoring & Correction
In the management of patients with diabetic ketoacidosis, electrolyte monitoring and correction play a vital role. DKA can cause various electrolyte imbalances, such as low potassium levels and metabolic acidosis.
Potassium levels are particularly important to monitor and correct in DKA. Low potassium levels can lead to heart rhythm abnormalities and neurological complications. Therefore, regular monitoring of serum potassium levels and potassium replacement is crucial to prevent these complications.
To correct electrolyte imbalances, various methods are utilised. One commonly used approach is giving potassium with the IV fluids. The appropriate dose of potassium is determined based on the severity of the potassium deficiency.
Additionally, hyperchloremic metabolic acidosis is a common finding in DKA, which occurs when there is an excess of chloride ions in the blood. This can be corrected by addressing the underlying cause of DKA, such as insulin deficiency, and restoring normal insulin levels.
Overall, carefully monitoring and correcting electrolyte imbalances, specifically potassium levels and hyperchloremic metabolic acidosis, are essential in the management of DKA. These measures help prevent potential complications and ensure the patient’s overall well-being.
Inpatient Management & Discharge Planning
When admitted to hospital with DKA, supportive care encompasses close monitoring of vital signs (such as heart rate and blood pressure), regular blood tests, and management of complications such as abdominal pain or infection. Additionally, patient education and support play an essential role in empowering individuals to manage their condition effectively.
To ensure a successful transition back to subcutaneous insulin from IV infusion, certain criteria must be met. These may include stable vital signs, normal ketones in the blood, and resolution of acidosis (blood returning to a normal pH). Equally as important is the ability to tolerate oral intake. On discharge, there should be discussion with a diabetic nurse or specialist to ensure understanding of at-home monitoring and self-care. A comprehensive discharge care plan should include follow-up appointments, medication instructions, and education about early signs of complications.
By following these steps for inpatient management and discharge planning, patients with DKA can receive the necessary care and support to achieve a successful recovery and continued management of their diabetes.
FAQs
Here, we will discuss some frequently asked questions about DKA, its causes, symptoms, treatment, and prevention.
High ketones? When to go to hospital
If you have diabetes and experience high ketones, it is important to know when to seek immediate medical attention. You should go to the hospital if you experience any of the following symptoms or circumstances:
1. Persistent high blood sugar levels: If your blood sugar level is consistently high for you and you are struggling to control them you should speak to your diabetic nurse, or if you are concerned and feeling unwell, attend A&E.
2. Have symptoms of DKA: These include frequent urination, excessive thirst, abdominal pain, vomiting, fruity-smelling breath, fatigue, and confusion. If you experience these symptoms, it is crucial to seek medical help.
3. High ketone levels: If you test your ketone levels regularly using urine or blood test strips and the results show high ketone levels, especially above 3 mmol/L or moderate to large on the scale provided with the test strip, it is crucial to go to the emergency department.
What are normal levels of ketones in blood?
The level of ketones in the blood can vary depending on various factors, but for individuals with diabetes, certain guidelines are followed to determine what is considered normal.
A blood ketone level of under 0.6mmol/L is generally considered normal for people with diabetes. This indicates that the body is efficiently breaking down glucose for energy and does not have excess ketones present.
If a blood ketone level falls between 0.6 and 1.5mmol/L, it is considered slightly high. In this case, it is recommended to retest the ketone levels in about two hours.
However, if the ketone levels range between 1.6 and 3mmol/L, there is an increased risk of developing diabetic ketoacidosis. It is important to consult with a diabetes care team or your usual healthcare provider in this situation to determine the best course of action to prevent DKA from occurring. If you have any symptoms of DKA and ketones in this range you should attend A&E.
If the blood ketone level exceeds 3mmol/L, it is considered high and requires immediate medical attention. High ketone levels can indicate a severe lack of insulin and may lead to the development of DKA, a potentially life-threatening condition.
How long does it take to recover from diabetic ketoacidosis?
The length of time it takes to recover from DKA and the duration of treatment necessary varies from person to person. Factors such as the individual’s overall health, the severity of the DKA episode, and adherence to treatment play a role in the recovery timeline. There is no “one size fits all” recovery timeline.
Can a non-diabetic get ketoacidosis?
Ketoacidosis is a condition more common in people with type 1 diabetes. It is also possible, however, in people with type 2 diabetes. The body produces high levels of ketones due to a lack of insulin, leading to a build-up of acid in the blood. While it is rare for non-diabetics to develop ketoacidosis, it can occur in certain situations. Sometimes a first presentation of ketoacidosis is how patients end up with their diagnosis of diabetes, but this tends to be in younger patients.
Prolonged fasting is one such situation where non-diabetics may be at risk of ketoacidosis. When the body doesn’t have enough glucose to use as fuel, it starts breaking down stored fat, resulting in the production of ketones. This can happen if someone is following a strict fasting regimen or not consuming enough carbohydrates for an extended period.
Severe alcoholism is another cause of ketoacidosis in non-diabetics. Excessive alcohol consumption can impair the liver’s ability to produce glucose, leading to a decrease in insulin levels and an increase in ketone production.
Certain medical conditions, such as pancreatitis, can also trigger ketoacidosis in non-diabetic individuals. Pancreatitis causes inflammation of the pancreas, affecting the production of insulin and resulting in elevated ketone levels.
Although ketoacidosis is rare in non-diabetics, it is essential to be aware of the potential causes and conditions that can lead to this condition.
What is the mortality rate of DKA?
The mortality rate of DKA varies depending on the severity of the condition and other underlying health factors. Generally, the mortality rate is estimated to be between 0.2% and 1%. However, it can be as high as 5-10%, especially in individuals with severe diabetes complications. Early diagnosis and treatment are key to reducing the risk of death due to DKA.
When would I be entitled to an insulin pump on the NHS?
Insulin pumps are a type of medical device used to help people with diabetes better manage their condition. They provide an automated way to deliver insulin to the body, helping regulate blood sugar levels. The NHS provides insulin pumps for those who meet specific criteria and can benefit from this form of treatment.
In England, adults with Type 1 Diabetes could be entitled to an insulin pump if they meet the following criteria:
- Have a proven history of multiple daily insulin injections (MDI) for at least 6 months and have been seen by a diabetes specialist or a MDI pump specialist in the year preceding assessment
- Demonstrate good glycaemic control, as evidenced by HbA1c levels within recommended targets
- Show evidence of commitment to take responsibility for their own care, such as regular monitoring of blood glucose levels and attendance at diabetes clinics
- Are aged 18 or over
Children aged 5 and above can be considered for an insulin pump if they meet the same criteria as adults. Those under 5 years old may also be eligible if they have advanced diabetes management skills.
It is important to note that eligibility for a pump on the NHS is subject to approval by a local Clinical Commissioning Group (CCG). It is best to discuss your specific situation with your diabetes specialist or healthcare team for more information.
