Diabetic Ketoacidosis (DKA)

1. What is diabetic ketoacidosis (DKA)?

Diabetic ketoacidosis (DKA) is a dangerous complication of diabetes caused by a lack of insulin in the body. Diabetic ketoacidosis occurs when the body is unable to use blood sugar (glucose) because there isn't enough insulin. Instead, it breaks down fat as an alternative source of fuel. This causes a build-up of a by-product called ketones.

2. What are ketones?

Ketones are made in the liver from the breakdown of fats. This is part of the body’s normal reaction to starvation.

3. Why does ketoacidosis develop?

In Type 1 diabetes, when there is not enough insulin in the body the liver continues to make more and more ketones. The rising ketone level makes the blood acidic. Lack of insulin also causes a high blood glucose level. Combination of high sugar and excess ketones causes dehydration and built up of acid in the body. If untreated, this situation can be life threatening. This situation can happen very quickly if there is another illness present, such as an infection or heart attack. This can be dangerous as it can lead to coma and even can be life threatening. But with proper precautions this complication is preventable to a great extent.

4. Is it seen only in type 1 diabetics?
It mainly affects persons with type 1 diabetes. But, it can happen with other types of diabetes, including type 2 diabetes and diabetes during pregnancy. So it is not exclusive to type 1 diabetes. DKA is sometimes the first sign of having diabetes.

5. What are the Risk factors/triggering events for DKA?

• Unrecognized diabetes
• Missing/stopping insulin
• Fever, infections
• Stressful periods (surgery, emotional stress, pregnancy, puberty)
• Very high blood glucose (>250-300 mg/dl) due to any other cause

6. What are the signs and symptoms of DKA?

a) High blood glucose levels- Glucose stays in the blood as it can’t move into the body cells without adequate insulin. Sometimes during illness blood glucose levels may not be high, for example in severe vomiting, but ketones may be present.

b) Positive blood or urine ketones are the most important sign

c) Passing urine frequently- The body tries hard to get rid of excess glucose and ketones in the urine. This increases the risk of becoming dehydrated.

d) Nausea and/or vomiting

e) Breathlessness. The body tries to get rid of excess ketones in the breath by over breathing. Ketones cause the breath to smell ‘fruity’ like nail polish remover.

f) Abdominal pain

g) Drowsiness or deterioration in consciousness.

7. How to check for ketones?
Ketones can be checked in the urine or blood. Most commonly urine testing is done in India.

Checking urine ketones

• Strips are available for checking ketones in urine. They are different from the strips meant for checking urine sugar.
• Dip the strip into urine and take it out.
• After 15 seconds, match the colour of the strip with ketones with the indicator given on the bottle.
• Read the result as nil or trace, small, moderate or large(more dark purple is the colour, more is the quantity of ketones)
• If your strips are very old, ketones may come falsely negative so if you have symptoms suggestive of DKA, contact doctor irrespective of the ketone test.

Blood ketones
Modern glucometers have function of testing blood ketones. Blood ketones become positive before urine ketones. So it can detect DKA at an earlier stage.

8. When to check for ketones?

• When you are ill. Ketones must be checked during illness even if your blood sugars are normal or low.
• When your sugars are consistently high (>300 mg/dl)
• When you have nausea or vomiting or any other symptom suggestive of DKA
• If you are on insulin pump and you have suspended or discontinued the pump for more than 1- 1½ hour.

9. How to protect yourself from DKA

• Do not stop insulin if you are on insulin
• During the periods of infection or stress
• Drink plenty of non glucose containing fluid (water, butter milk, salted lemon water, tea without sugar
• Take rest
• Check your blood sugar frequently and take extra insulin as required
• Test for ketones
• Contact the doctor urgently if you have any symptoms suggestive of DKA or testing for ketones is positive.

10. What is the treatment?
Urgent treatment is needed for this condition. Hospitalization is necessary in most of the cases for giving insulin intravenously and for giving intravenous fluids. You need to discuss with your doctor the plan of treatment.