Diabetic ketoacidosis

Overview

Diabetic ketoacidosis is a serious complication of diabetes.

The condition develops when the body can't produce enough insulin. Insulin plays a key role in helping sugar — a major source of energy for muscles and other tissues — enter cells in the body.

Without enough insulin, the body begins to break down fat as fuel. This causes a buildup of acids in the bloodstream called ketones. If it's left untreated, the buildup can lead to diabetic ketoacidosis.

If you have diabetes or you're at risk of diabetes, learn the warning signs of diabetic ketoacidosis and when to seek emergency care.

Symptoms

Diabetic ketoacidosis symptoms often come on quickly, sometimes within 24 hours. For some, these symptoms may be the first sign of having diabetes. Symptoms might include:

• Being very thirsty
• Urinating often
• Feeling a need to throw up and throwing up
• Having stomach pain
• Being weak or tired
• Being short of breath
• Having fruity-scented breath
• Being confused

More-certain signs of diabetic ketoacidosis — which can show up in home blood and urine test kits — include:

• High blood sugar level
• High ketone levels in urine

When to see a doctor

If you feel ill or stressed or you've had a recent illness or injury, check your blood sugar level often. You might also try a urine ketone test kit you can get at a drugstore.

Contact your health care provider right away if:

• You're throwing up and can't keep down food or liquid
• Your blood sugar level is higher than your target range and doesn't respond to home treatment
• Your urine ketone level is moderate or high

Seek emergency care if:

• Your blood sugar level is higher than 300 milligrams per deciliter (mg/dL), or 16.7 millimoles per liter (mmol/L) for more than one test.
• You have ketones in your urine and can't reach your health care provider for advice.
• You have many symptoms of diabetic ketoacidosis. These include excessive thirst, frequent urination, nausea and vomiting, stomach pain, weakness or fatigue, shortness of breath, fruity-scented breath, and confusion.

Remember, untreated diabetic ketoacidosis can lead to death.

Causes

Sugar is a main source of energy for the cells that make up muscles and other tissues. Insulin helps sugar enter the cells in the body.

Without enough insulin, the body can't use sugar to make the energy it needs. This causes the release of hormones that break down fat for the body to use as fuel. This also produces acids known as ketones. Ketones build up in the blood and eventually spill over into the urine.

Diabetic ketoacidosis usually happens after:

• An illness. An infection or other illness can cause the body to make higher levels of certain hormones, such as adrenaline or cortisol. These hormones work against the effects of insulin and sometimes cause diabetic ketoacidosis. Pneumonia and urinary tract infections are common illnesses that can lead to diabetic ketoacidosis.
• A problem with insulin therapy. Missed insulin treatments can leave too little insulin in the body. Not enough insulin therapy or an insulin pump that doesn't work right also can leave too little insulin in the body. Any of these problems can lead to diabetic ketoacidosis.

Other things that can lead to diabetic ketoacidosis include:

• Physical or emotional trauma
• Heart attack or stroke
• Pancreatitis
• Pregnancy
• Alcohol or drug misuse, particularly cocaine
• Certain medicines, such as corticosteroids and some diuretics

Risk factors

The risk of diabetic ketoacidosis is highest if you:

• Have type 1 diabetes
• Often miss insulin doses

Sometimes, diabetic ketoacidosis can occur with type 2 diabetes. In some cases, diabetic ketoacidosis may be the first sign of having diabetes.

Complications

Diabetic ketoacidosis is treated with fluids, electrolytes — such as sodium, potassium and chloride — and insulin. Perhaps surprisingly, the most common complications of diabetic ketoacidosis are related to this lifesaving treatment.

Possible complications of the treatments

Treatment complications include:

• Low blood sugar, also known as hypoglycemia. Insulin allows sugar to enter cells. This causes the blood sugar level to drop. If the blood sugar level drops too quickly, the drop can lead to low blood sugar.
• Low potassium, also known as hypokalemia. The fluids and insulin used to treat diabetic ketoacidosis can cause the potassium level to drop too low. A low potassium level can affect the heart, muscles and nerves. To avoid this, potassium and other minerals are usually given with fluid replacement as part of the treatment of diabetic ketoacidosis.
• Swelling in the brain, also known as cerebral edema. Adjusting the blood sugar level too quickly can cause the brain to swell. This appears to be more common in children, especially those with newly diagnosed diabetes.

Untreated, diabetic ketoacidosis can lead to loss of consciousness and, eventually, death.

Prevention

There are many ways to prevent diabetic ketoacidosis and other diabetes complications.

• Manage your diabetes. Make healthy eating and physical activity part of your daily routine. Take diabetes medicines or insulin as directed.
• Monitor your blood sugar level. You might need to check and record your blood sugar level at least 3 to 4 times a day, or more often if you're ill or stressed. Careful monitoring is the only way to make sure that your blood sugar level stays within your target range.
• Adjust your insulin dosage as needed. Talk to your health care provider or diabetes educator about how to make your insulin dosage work for you. Consider factors such as your blood sugar level, what you eat, how active you are, and whether you're ill. If your blood sugar level begins to rise, follow your diabetes treatment plan to return your blood sugar level to your target range.
• Check your ketone level. When you're ill or stressed, test your urine for excess ketones with a urine ketones test kit. You can buy test kits at a drugstore. If your ketone level is moderate or high, contact your health care provider right away or seek emergency care. If you have low levels of ketones, you may need to take more insulin.
• Be prepared to act quickly. If you think you have diabetic ketoacidosis because your blood sugar is high and you have too many ketones in your urine, seek emergency care.

Diabetes complications are scary. But don't let fear keep you from taking good care of yourself. Follow your diabetes treatment plan carefully. Ask your diabetes treatment team for help when you need it.

Diagnosis

A physical exam and blood tests can help diagnose diabetic ketoacidosis. In some cases, other tests may be needed to help find what caused the diabetic ketoacidosis.

Blood tests

Blood tests used in the diagnosis of diabetic ketoacidosis will measure:

• Blood sugar level. If there isn't enough insulin in the body to allow sugar to enter cells, the blood sugar level will rise. This is known as hyperglycemia. As the body breaks down fat and protein for energy, the blood sugar level will keep rising.
• Ketone level. When the body breaks down fat and protein for energy, acids known as ketones enter the bloodstream.
• Blood acidity. A too-high blood ketone level will cause the blood to become acidic. This can change how organs throughout the body work.

Other tests

Tests that can help find health problems that might have contributed to diabetic ketoacidosis and check for complications might include:

• Blood electrolyte tests
• Urinalysis
• Chest X-ray
• A recording of the electrical activity of the heart, also known as an electrocardiogram

Treatment

If you're diagnosed with diabetic ketoacidosis, you might be treated in the emergency room or admitted to the hospital. Treatment usually involves:

• Fluids. Fluids replace those lost through too much urinating. They also thin out the blood sugar. Fluids can be given by mouth or through a vein. When given through a vein, they're called IV fluids.
• Electrolyte replacement. Electrolytes are minerals in the blood, such as sodium, potassium and chloride, that carry an electric charge. Too little insulin can lower the level of several electrolytes in the blood. IV electrolytes are given to help keep the heart, muscles and nerve cells working as they should.
• Insulin therapy. Insulin reverses diabetic ketoacidosis. In addition to fluids and electrolytes, insulin is given, usually through a vein. A return to regular insulin therapy may be possible when the blood sugar level falls to about 200 mg/dL (11.1 mmol/L) and the blood is no longer acidic.

Preparing for your appointment

Diabetic ketoacidosis is life-threatening. If you develop mild symptoms, contact your health care provider immediately.

Call 911 or your local emergency number if:

• You can't reach your care provider
• Your symptoms are getting worse
• Your symptoms are already very bad

A health care provider who sees you for possible diabetic ketoacidosis needs answers to these questions as quickly as possible:

• What are your symptoms?
• When did your symptoms develop? Are they getting worse?
• Have you been diagnosed with diabetes?
• Have you recently checked your blood sugar level?
• Have you recently checked your ketone level?
• Have you lost your appetite?
• Can you keep fluids down?
• Are you having trouble breathing?
• Do you have chest pain?
• Have you had a recent illness or infection?
• Have you had recent stress or trauma?
• Have you recently used alcohol or recreational drugs?
• How closely have you been following your diabetes treatment plan?
• How well have you been managing your diabetes just before these symptoms started?