Diabetic Ketoacidosis

What is diabetic ketoacidosis?

Diabetic ketoacidosis (DKA) is a problem that can develop when your diabetes mellitus is not controlled. Diabetes prevents your body from making enough insulin to decrease the amount of glucose (sugar) in your blood. Insulin is a hormone that helps move your blood sugar into body cells to be used for energy. With uncontrolled diabetes, you do not have enough insulin and the level of sugar in your blood can become higher than is safe. DKA happens when your blood sugar is not used for energy and your body uses body fat instead. When body fat is used for energy, acidic chemicals called ketones are created in your blood. This is called ketoacidosis. The high sugar level, ketones, and acid in your blood can cause you to become very sick.

What are the types of diabetes mellitus?

• Type 1 diabetes: Type 1 diabetes is also called insulin-dependent diabetes mellitus (IDDM). Type 1 diabetes is an autoimmune disease. An autoimmune disease is a condition that causes your body's defense system to attack some of your own cells. Normally, when your blood glucose level increases, the pancreas (an organ that lies behind the stomach) makes insulin. When you have type 1 diabetes, your body's defense system has destroyed the cells in the pancreas that make insulin.
  
  
• Type 2 diabetes: Type 2 diabetes is also called non-insulin dependent diabetes mellitus (NIDDM). Type 2 diabetes can cause insulin resistance. This means your pancreas still makes insulin but your body cannot use it. The pancreas keeps making insulin to try to control your blood sugar. After many years, your pancreas may stop making insulin.

What causes diabetes ketoacidosis?

DKA may be the first sign that you have diabetes mellitus. The following may lead to increased blood sugar levels and DKA:

• You are not taking or getting the right insulin doses.
  
  
• You are not taking or getting your insulin at all.
  
  
• You have an illness or infection, such as pneumonia (lung infection), or a urinary tract infection.
  
  
• Your insulin pump stops working correctly.

What increases my risk for diabetic ketoacidosis?

The following may increase your risk for DKA:

• Alcohol and street drugs: Alcohol can make your blood sugar levels drop too low. Cocaine is the most common street drug that may increase your risk for DKA.
  
  
• Medical conditions: Any condition that stresses your body may lead to DKA, such as a stroke or heart attack. Severe skin burns, surgery, and accidents may also increase your risk for DKA.
  
  
• Menstruation: Female menstrual cycles (monthly period) may change how the body reacts to glucose leading to DKA.
  
  
• Mental disorders: A mental disorder, such as depression (deep sadness) or an eating disorder, can lead to DKA.
  
  
• Frequent high blood sugar levels: Blood sugar levels that are often higher than they should be can change how your body processes glucose.
  
  
• Past DKA: Your risk increases if you had DKA before.
  
  
• Medicines: Medicines such as steroids, high blood pressure, and heart medicines can increase your risk. Certain medicines used to treat mental illness may also increase your risk for DKA.
  
  
• Lack of insulin: Your risk increases if you stop your insulin, such as you run out of it or you are trying to lose weight.
  
  
• Illness: Vomiting and diarrhea from an illness, such as the flu, can increase your risk.

What are the signs and symptoms of diabetic ketoacidosis?

With DKA, you may feel very thirsty, and urinate more than normal. You also may have any of the following signs and symptoms:

• Abdominal pain, nausea, and vomiting. You may vomit blood that looks like coffee grounds.
  
  
• Blurry vision.
  
  
• Decreased appetite for food, and weight loss.
  
  
• Dry mouth, eyes, and skin. Your face also may be red and feel warm.
  
  
• Fast, deep breathing. You also may feel like your heart is beating faster than normal.
  
  
• Feeling very weak, tired, and confused.
  
  
• Fruity-smelling breath.
  
  
• Mood changes and irritability (easily angered).

How is diabetic ketoacidosis diagnosed?

Your caregiver may ask about your health history and any symptoms you are having. If you have known diabetes, he may ask about how you manage your diabetes. Your caregiver will examine you, and look for signs of dehydration. He will also check your height and weight. You also may need the following to diagnose DKA:

• Blood tests: Your blood will be tested to check your blood sugar and acid levels. Blood tests will also show ketone levels, and if you are lacking body salts from dehydration.
  
  
• Urine tests: Your urine will be tested for ketones, and the level of blood sugar and acid.
  
  
• Cultures: Cultures may be done to test you for an infection. Cultures can be done with your blood or urine.
  
  
• Chest x-ray: This is a picture of your lungs and heart. Caregivers may use the x-ray to look for signs of infection, such as pneumonia.
  
  
• Electrocardiogram: An electrocardiogram (ECG) helps caregivers see your heart activity. If you have a low level of potassium, your heartbeat may become abnormal. Caregivers may need to prepare your skin by cleaning it with a gritty lotion. Sticky pads are placed on your chest, arms, and legs. Each sticky pad has a wire that is hooked to a machine or TV-type screen. A short period of electrical activity in your heart muscle is recorded. Caregivers will look closely for certain problems or changes in how your heart is working.

How is diabetic ketoacidosis treated?

The goal of treatment is to replace lost body fluids, and to bring blood sugar levels back to normal. Treatment also works to decrease the amount of ketones and acid in your body. Treatment may prevent medical problems caused by DKA, and may save your life. You may have the following treatments:

• IV fluids: Fluids are given through an IV (intravenous) to treat your dehydration. An IV is a tube placed in your vein so caregivers can give you medicine or liquids. Electrolytes (body salts) may be added to the fluids to replace what has been lost from your body. The most common body salt that needs to be replaced is potassium.
  
  
• Insulin: Insulin is given to decrease the amount of sugar in your blood. You may need continuous insulin given until your blood sugar levels become normal. The insulin will also work to decrease the acid level in your body.
  
  
• Glucose: Glucose may be given when your blood sugar levels begin to decrease. This is to prevent low blood sugar while you are getting continuous insulin.

What are the risks of diabetic ketoacidosis?

• Treatment may cause your blood sugar levels to become too low. Very low blood sugar levels may cause seizures (convulsions), and you may become unconscious. Unconscious means you look like you are sleeping but you cannot be woken up. Fluid replacement may cause fluid buildup in your body, and you may have trouble breathing. Fluids may also cause cerebral edema (water around the brain), which may be life-threatening.
  
  
• When you have DKA and it is not treated, you are at risk for severe dehydration. The loss of body salts may cause life-threatening abnormal heartbeats. Blood flow to your organs may be decreased and cause organs, such as your kidneys, to fail. Decreased blood flow to your brain may lead to swelling, seizures, coma, and death. Ask your caregiver for more information about the treatment, care, and risks of DKA.

What can I do to prevent diabetic ketoacidosis?

The best way to prevent DKA is to control your diabetes. The following may help decrease your risk for DKA:

• Check your blood and urine for ketones: Follow your caregiver's instructions about when you should check your blood or urine for ketones. Your caregiver may give you a special machine to check your blood ketones. Urine ketones can be checked with special sticks you dip in your urine.
  
  
• Know how to manage your sick days: When you are sick, you may not eat as much as you normally would. You may need to change the amount of insulin you give yourself. You may need to check your blood sugar levels more often. You also may need to check for ketones. Make a plan with your caregiver about how to manage your diabetes when you are sick.
  
  
• Know how your insulin pump works: If you use an insulin pump, know how to use it, and what the alarms mean. If your pump shows an error, call the manufacturer (maker). Also call your caregiver. You may need to switch to insulin shots while your pump is being fixed. Ask your caregiver for instructions on how to change to insulin shots.
  
  
• Know the signs of DKA: If you have signs of DKA, increase your fluids and take your insulin as directed by your caregiver.
  
  
• Seek help if you have mental health issues: Talk to a mental health caregiver to help you cope with your diabetes better.
  
  
• Call your diabetes team when needed: Ask your caregiver about a diabetes healthcare team that you can call for help. Call the team if your blood sugar levels are high, or you have ketones in your blood or urine. A diabetes team is available for any questions or concerns you may have about your diabetes.

How can I best manage my diabetes?

It is very important to manage your diabetes. Talk to your caregiver about what blood sugar levels are safe for you. You can do the following to help manage your diabetes:

• Check your blood sugar levels: Follow your caregiver's instructions about when to test your blood sugar levels. If your blood sugar level is too high, give yourself insulin as directed by your caregiver.
  
  
• Do not smoke: People who have diabetes are at an increased risk for other diseases. Smoking, and being around others who smoke, increases the risk even more. If you smoke, ask your caregiver for information about how to stop.
  
  
• Get yearly eye exams: Diabetes can cause changes in your vision. Diabetes can also lead to eye damage if it is not managed properly. Make sure you see a caregiver to check your eyes each year.
  
  
• Drink enough liquids: Men 19 years old and older should drink about 3 liters of liquid each day (about 13 eight-ounce cups). Women 19 years old and older should drink about 2.2 iters of liquid each day (about 9 eight-ounce cups). Follow your caregiver's advice if you must change the amount of liquid you drink. High sugar or carbohydrate drinks may make your blood sugar go up. Alcohol may make your blood sugar drop too low. Liquids that will not affect your blood sugar are water, sugar-free drinks, tea, and coffee. Try to drink enough liquid each day, and not just when you feel thirsty.
  
  
• Keep a healthy weight: Weighing more than what is healthy for you increases your risk for problems from your diabetes. Being overweight also increases your risk for heart disease. Talk to your caregiver about what weight is healthy for you. You and your caregiver can work together to find the best weight loss plan for you.
  
  
• Eat healthy foods: You may need to change the way you eat to control your blood sugar levels. Foods lower in sugar, fat, and cholesterol are best. Eat a variety of healthy foods from each food group every day. Include fruits, vegetables, breads, dairy products, and protein (such as chicken, fish, and beans). Healthy foods may help you feel better and have more energy. Your caregiver or dietitian can help you plan meals and snacks.
  
  
• Exercise: You should exercise for at least 2 to 3 hours each week. Exercise may increase your energy and help with weight control. Exercise also helps reduce the risk for other diseases, such as high blood pressure and heart problems. Check with your caregiver before you start an exercise program. Together you can plan an exercise program that is right for you. Your caregiver will give you special directions to help control your blood sugar during exercise. You may need to check your blood sugar more often during exercise.
  
  
  • Always bring a snack with you when you exercise, in case your blood sugar gets too low.
    
    
  • Do not exercise if your blood sugar is less than 100 mg/dL: If your blood sugar is less than 100 mg/dL, eat or drink a carbohydrate snack before you exercise.
    
    
  • Avoid vigorous activities if you have ketones in your urine.
  
  
• Make sure you are vaccinated: Vaccinations are a shot of medicine to help prevent illness and disease. Ask your caregiver about the vaccinations that you may need.
  
  
  • Vaccines: To prevent influenza (flu), all adults should get the influenza vaccine. They should get it every year as soon as it becomes available. The pneumococcal vaccine is given to adults aged 65 years or older to prevent pneumococcal disease, such as pneumonia. People aged 19 to 64 years at high risk for pneumococcal disease also should get the pneumococcal vaccine. It may need to be repeated 5 years later.
    
    
  
  
• Wear or carry medical alert identification: Wear a bracelet or necklace, or carry a card that says you have diabetes. This can help others know you have diabetes if you become ill. Ask your caregiver where you can get medical alert identification.

Where can I find support and more information?

Diabetes is a life-changing disease for you and your family. Talk to your caregivers, family, or friends about your feelings. You also may want to join a support group. A support group is a group of people who also have diabetes. Contact the following:

• American Diabetes Association
  1701 North Beauregard Street
  Alexandria , VA 22311
  Phone: 1- 800 - 342-2383
  Web Address: http://www.diabetes.org
  

• National Diabetes Information Clearinghouse
  1 Information Way
  Bethesda , MD 20892-3560
  Phone: 1- 800 - 860-8747
  Web Address: www.diabetes.niddk.nih.gov/
  

When should I contact my caregiver?

Contact your caregiver if:

• Your blood sugar levels are lower or higher than your caregiver says they should be.
  
  
• You have a fever or chills.
  
  
• You have ketones in your blood or urine.
  
  
• You are more thirsty than usual.
  
  
• You are urinating more often than usual.
  
  
• You have questions or concerns about your condition or treatment.

When should I seek immediate help?

Seek care immediately or call 911 if:

• You have fruity smelling breath.
  
  
• You have very bad, new stomach pain and are vomiting.
  
  
• You are more drowsy or sleepy than normal.
  
  
• You begin to breathe fast, or are short of breath.
  
  
• You become weak and confused.
  
  
• You have a seizure.

Care Agreement

You have the right to help plan your care. Learn about your health condition and how it may be treated. Discuss treatment options with your caregivers to decide what care you want to receive. You always have the right to refuse treatment.

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The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.

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