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Diabetes ketoacidosis by Shu Golda.
Diabetes ketoacidosis(DKA) is a serious diabetes complication, where the body produces excess blood acids (ketones). It results from severe insulin deficiency, which leads to low blood glucose levels (hypoglycemia).

Glucose is the main source of energy for most cells in the body, and insulin helps promote the uptake of glucose found in the blood into cells. So insulin deficiency will result in little or no glucose uptake into cells. This will cause the body to resort to the breakdown of free fatty acids as a source of energy leading to the buildup of ketones or keto acids. The buildup of ketones causes the blood to become acidic. Ketones are acidic chemicals and at high concentrations, they become toxic. They generally provide a small amount of energy to the body and if this happens for too long, you suddenly become ill. DKA mostly occurs in type 1 diabetes (insulin-dependent diabetes), but it can also be seen in type 2 diabetes and gestational diabetes. Factors that can trigger DKA are discussed in the subsequent paragraph.

In people with diabetes, missing one or more insulin dose, or not using the right amount of insulin can lead to DKA. An illness or infection, as well as some drugs (oral diazoxide, octreotide, somatostatin), can also prevent the body from using insulin properly, and this can lead to DKA. Other possible triggers include;

  • Stress
  • A heart attack
  • Excessive alcohol
  • Fasting and malnutrition in people with a history of excessive alcohol
  • Drug abuse, especially cocaine
  • Some medications, examples diazoxide, octreotide
  • Severe dehydration
  • Acute major illnesses such as sepsis, pancreatitis, or myocardial infarction.

The metabolic changes that accompany pregnancy predispose to ketosis. The factors that contribute to the increased risk of diabetic ketoacidosis and their differential impact at various trimesters of pregnancy are discussed below.

Insulin antagonistic state.

Pregnancy is a state of insulin resistance. Insulin sensitivity has been demonstrated to fall by as much as 56% through 36 weeks of gestation. The production of insulin-antagonistic hormones like human placental lactogen, prolactin, and cortisol all contribute to this. The insulin requirement, for this reason, progressively rises during pregnancy, explaining the higher incidence of diabetic ketoacidosis in the second and third trimesters. Also, the physiological rise in progesterone with pregnancy decreases gastrointestinal motility that contributes to an increase in the absorption of carbohydrates, thereby promoting hyperglycemia.

Accelerated starvation.

In pregnancy, there is a relative state of accelerated starvation, especially in the second and third trimesters. The fetus and the placenta use large amounts of maternal glucose as a major source of energy, and this leads to decreased maternal fasting glucose. This, associated with relative insulin deficiency, leads to an increase in free fatty acids, which are then converted to ketones in the liver.

Effect of emesis.

Nausea and vomiting are common due to increased human chorionic gonadotrophin in early pregnancy and increased esophageal reflux in later stages. The resulting stress and fasting state later increases insulin-antagonistic hormones. This, along with the dehydration that ensues contributes to the development of ketoacidosis.

Lowered buffering capacity.

The increased minute alveolar ventilation in pregnancy leads to respiratory alkalosis, and this is compensated by increased renal excretion of bicarbonate. The net result is a lowered buffering capacity when exposed to an acid load like ketones. The clinical implication of these metabolic changes is not only that pregnant diabetics are at risk of developing ketoacidosis, but this can occur rapidly and at a much lower glucose level compared to non-pregnant diabetics, as seen in our illustrated case above.

Symptoms of DKA include:

Symptoms include an increase in thirst, cool skin,  frequent urination, dehydrated or dry mouth, nausea and vomiting, abdominal pain, weakness or fatigue, shortness of breath, fruity-scented breath, and confusion.

Specific signs  which can be detected through home blood and urine testing kits include:

– High blood sugar level (hyperglycemia)

– High ketone levels in urine

Diagnosis of DKA 

Diabetes ketoacidosis can be diagnosed by carrying out a physical examination (by a physician) and a series of blood tests.

Blood sugar level, ketone level, and blood acidity are measured.

  • Additional tests can be carried out to identify the underlying health problems that might have contributed to diabetic ketoacidosis and to check for complications, and the tests might include;
  • Blood electrolyte tests (sodium, potassium) to assess metabolic function
  • Urinalysis,
  • Chest X-ray and a recording of the electrical activity of the heart (electrocardiogram).
  • Blood pressure
  • Arterial blood gas, to determine the acidity of blood in arteries.
  • Check blood pressure

Treatment 

Treatment for DKA usually involves:

  • Fluid replacement. Fluids are administered through the mouth or vein to help replace those lost through excessive urination and to dilute the excess sugar in the blood.
  • Electrolyte replacement.  The absence of insulin can lower the level of several electrolytes in the blood. Thus administration of electrolytes through the vein helps to keep the heart, muscles, and nerve cells functioning normally.
  • Insulin therapy. Insulin reverses the processes that cause diabetic ketoacidosis, and it is administered through the vein. Intravenous insulin therapy can be stopped when blood sugar levels drop to about 200mg/dl (11.1mmol/L), and blood is no longer acidic, only then subcutaneous insulin therapy can be resumed.

Likely complications of treatment

Some effects or complications that might result from treatment include:

  • Hypoglycemia (Excessive drop in blood sugar). If excessive insulin is administered during therapy, it can lead to a fall in blood glucose levels below the normal. This situation is referred to as hypoglycemia. Hypoglycemia can also occur as a result of a quick drop in glucose levels upon administration of insulin.
  • Cerebral edema (brain swelling): A quick drop in blood glucose levels during adjustment can lead to brain swelling. It is more common in children.
  • Hypokalemia (drop in blood potassium): Insulin and fluids used in the treatment of diabetic ketoacidosis can cause blood potassium levels to drop excessively. This decrease in potassium concentration may cause harm to the heart, muscles, and nerves.

Regardless of all these risks, if left untreated, the risks are worse. Diabetic ketoacidosis can lead to loss of consciousness and, eventually, death.

Who is at risk for developing diabetic ketoacidosis?

People who have the following conditions are prone to diabetic ketoacidosis:

  • Type 1 diabetes patients
  • Are under the age of 19
  • Smokers
  • Stressed
  • Addicts to alcohol or other drugs
  • Have had a heart attack or stroke
  • Physical or emotional trauma

Prevention

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To prevent diabetes ketoacidosis, do the following;

  • Check your blood sugar levels at least 3 times per day, especially if you feel ill. This will help you maintain glucose levels at a target range.
  • Adjust your insulin dosage to blood sugar levels. This should be done with the help of your doctor or diabetes counselor. Also, pay attention to lifestyle changes like your diet and physical activity.
  • Check your ketone levels regularly, especially when you feel you are ill or stressed, using the urine ketone test kit. If you find any irregularities (moderate or high ketone levels), report to your doctor.
  • Stay committed to managing your diabetes by maintaining healthy eating habits and making physical activity part of your daily routine. Also, take your diabetes medications as directed and on time.
  • Report to the doctor urgently if you notice high blood glucose levels and or ketones in your urine. Quick action reduces the risk of complications.

Diabetic ketoacidosis is a complication of diabetes mellitus, especially type 1. However, it can be prevented if treatment and lifestyle changes are carefully respected. If you notice any signs of ketoacidosis, seek urgent help from your doctor, they will come up with a treatment plan to adjust the situation.

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Reference.

 

https://www.diabetes.org/diabetes/complications/dka-ketoacidosis-ketones-DKA (Ketoacidosis) & Ketones

Abdulmoein Eid Al – Agha (2014). Diabetes ketoacidosis. http://aagha.kau.edu.sa

https://www.health.harvard.edu/a_to_z/diabetic-ketoacidosis-a-to-z