Diabetic Ketoacidosis Treatment

Diabetic ketoacidosis is a life-threatening medical condition that is a complication of diabetes mellitus that is not in control.  It is more common among type 1 diabetics that have no insulin but it can also be seen in severe cases of type 2 diabetes.  In diabetic ketoacidosis, there are ketones in the bloodstream and urine because the fat in the body is broken down with ketones as a byproduct.

Diabetic ketoacidosis occurs when the body isn’t making enough insulin by the pancreatic islet cells. In a normal person, insulin is secreted by the pancreas in response to elevated blood sugar levels.  The insulin helps glucose (sugar) to enter the cells to be used as cellular fuel.

If insulin is absent, the body breaks down fatty acids to be used for fuel.  Ketones build up in the urine and blood, leading to the condition known as diabetic ketoacidosis.  The main cause is being a type 1 diabetic who has not taken enough insulin.

Symptoms of Diabetic Ketoacidosis

The signs and symptoms of diabetic ketoacidosis can come on suddenly, within a day or so of having no insulin.  When signs and symptoms do show up, the patient may have any or all of the following symptoms:

• Confusion 
• Breath that smells fruity
• Shortness of breath
• Tiredness or weakness
• Pain in the abdomen
• Nausea and vomiting
• Increased frequency of urination
• Being excessively thirsty

Clinical signs that the individual has diabetic ketoacidosis includes have extremely high blood sugar levels as well as elevated levels of ketones in the urine.

Causes of Diabetic Ketoacidosis

The main source of cellular fuel is glucose.  All of the cells of the body rely on glucose to make energy to allow the cells to function in whatever capacity they happen to be in.  When insulin is lacking, the body is unable to use glucose as fuel.  These causes a hormonal release of hormones that allow for the breakdown of fatty acids to be used as fuel.  The byproduct of this metabolism is ketones.  The ketones build up in the blood and are excreted by the kidneys.

Common triggers for the development of diabetic ketoacidosis include the following:

• Being sick – Any type of infection or other bodily illness can result in excessive amounts of cortisol and epinephrine to be released by the adrenal glands. These hormones act against insulin so the insulin cannot work.  This triggers the individual to develop diabetic ketoacidosis.  Many cases of diabetic ketoacidosis are the result of having a bladder infection or pneumonia.
• Insulin therapy issues – If the type 1 diabetic misses too many insulin doses or isn’t getting enough insulin, there will be insufficient amounts of insulin to put glucose into the cells.  This triggers the development of ketoacidosis because the cells need to get cellular fuel by some other source.
• Physical or emotional trauma – This causes the release of epinephrine and cortisol, which counteract insulin.
• Alcohol or cocaine use – This can result in the lack of ability of the body to recognize and make use of insulin.
• Various medications – This includes some types of diuretics and corticosteroids given by injection or orally.
• Heart attack – This can cause excessive amounts of cortisol and epinephrine, leading to a blockage of insulin use.

Risk Factors for Diabetic Ketoacidosis

The major risk factor for diabetic ketoacidosis is being a type 1 diabetic and missing insulin doses or taking in too little insulin.  In rare cases, a type 2 diabetic will have diabetic ketoacidosis, especially if it is left untreated for too long.

Complications of Diabetic Ketoacidosis

The major complications of ketoacidosis include over-treating the condition by giving too much fluids, the wrong electrolytes (sodium, chloride, and potassium), or insulin.  Complications of treating diabetic ketoacidosis include the following:

• Hypoglycemia or Low Blood Sugar – This happens when the individual is over-treated with insulin and too much glucose is gotten rid of so the blood glucose level drops very quickly. Low glucose levels can result from this.
• Hypokalemia (low potassium) – When fluids and insulin are given in excess to treat the condition, this can cause the potassium level to become too low.  Low potassium levels can adversely affect the nerves, muscles, and heart electrical system.
• Cerebral edema (swelling of the brain) – When the blood sugar level is treated too aggressively, it can cause a water imbalance to occur in the brain and the brain begins to swell. This is most common among new diabetics and children who suffer from the disease.

If the condition is left untreated, the confusion extends itself to unconsciousness, which can ultimately result in the death of the patient.

Testing for Diabetic Ketoacidosis

The diagnosis can be suspected in anyone who has the symptoms described above and who has blood levels of glucose that are extremely high. The doctor will likely do blood testing that includes a blood glucose level and a blood ketone level.  The urine will be checked for evidence of ketones in the urine. An arterial blood gas can be checked, which will show metabolic acidosis.  Acidosis can be dangerous to the functioning of most bodily organs.

Other tests that may be done to define diabetic ketoacidosis include a urinalysis, blood electrolyte testing, and an EKG to see if the electrolyte imbalance is negatively impacting the heart. A chest x-ray can be done to see if pneumonia is the underlying cause of the disorder.

Treatment for Diabetic Ketoacidosis

Treatment for diabetic ketoacidosis can be tricky.  The goal is to provide the body with enough insulin and to make sure that the electrolytes and fluid balance are normal. Common treatments for diabetic ketoacidosis include the following:

• Electrolyte replacement therapy – Electrolytes include the sodium, potassium, and chloride levels. When insulin is missing, you can get low levels of electrolytes, which can cause damage to the electrical system of the heart and damage to cellular functions of the muscles and nerves.
• Fluid replacement therapy – Urine is being put out too much by the kidneys in an effort to get rid of the ketones in the bloodstream. This can cause dehydration that can be managed by providing the patient with extra fluids by intravenous means.  The extra fluid usually does not contain sugar but instead helps to dilute the amount of excess glucose in the system.
• Insulin treatment – The goal of treating diabetic ketoacidosis is to replace the missing insulin so that it can put the glucose back into the cells and stop the breakdown of fatty acids into ketones.  Insulin is usually given by IV in order to allow for a steady dose of insulin until the blood sugars normalize.

References:

• Diabetic ketoacidosis. http://www.mayoclinic.org/diseases-conditions/diabetic-ketoacidosis/basics/definition/con-20026470.
• Diabetic ketoacidosis treatment. http://www.aafp.org/afp/2013/0301/afp20130301p337-f1.pdf.