Diabetic ketoacidosis (DKA) is a severe life-threatening condition that means you have too many ketones in your body. Ketones are caused by the breakdown of fat when there isn’t enough insulin to meet your body’s needs. When they build up, the result is acidosis (too much acid in the blood). If not treated, this can lead to death. Usually blood glucose levels are elevated (>250 mg/dL or >13.9 mmol/L) but not always. It is the presence of too many ketones in the blood and urine that defines DKA.

DKA can be caused by insulin lack as well as not giving enough insulin when sick or stressed. This can happen even with normal blood glucose levels.

People with diabetes must NEVER run out of insulin. A pharmacy can give you regular insulin (a vial and syringe) without a prescription if you can prove you have diabetes—bring in an empty vial of insulin or a pen or your meter. You can also go to any urgent-care center or emergency room and tell them you have diabetes and need insulin.

You can give a dose of regular insulin every 6 hours and keep enough insulin in your body.

Causes

Illness is a common precipitating factor in DKA because the body’s response to sickness is to release hormones that can act to counter insulin, raising blood glucose. Also, because a person may not be able to eat, insulin doses at mealtime may not be taken, leading to insulin deficiency. A third factor is dehydration, which can come along with vomiting and inadequate fluid consumption.

Insulin deficiency, and DKA, can also onset rapidly in the event of an insulin pump malfunction. A common cause of DKA in pump users is not using backup insulin (in pens or syringes) when blood glucose is high or ketones are detected in the urine.

Another unfortunate cause of DKA is insulin omission. Some people don’t take insulin because they can’t afford it, they don’t know how to take the medication properly, or they have a fear of insulin. Other people purposefully skip insulin doses for weight management purposes, particularly adolescent girls. DKA is associated with a variety of psychosocial factors, including an unstable or dysfunctional family, language barriers, psychiatric or eating disorders, and financial insecurity. DKA is seen in people who have the highest A1C levels, especially in teenagers and transitioning adults, indicating that an overall lack of adherence with diabetes management can lead to serious acute issues.

Children

Approximately one-third of children with new-onset type 1 diabetes are in DKA when they are diagnosed. Parents often feel guilty that they didn’t realize that something was wrong sooner and worry that they did something to have caused the diabetes. Both of these feelings are natural but are simply not true. Even some healthcare providers have a hard time recognizing symptoms of diabetes in a child and don’t test for diabetes.

Adults

Often DKA in adults occurs either because of an illness that isn’t treated properly with increased insulin doses and carbohydrates or because of a lack of access to medical care, which means patients can’t get their insulin prescriptions refilled and run out of insulin. Sometimes young adults and sometimes older adults simply rebel and stop giving enough insulin.

How to Treat DKA

Once treatment is started, a person starts to feel much better within a few hours.

Fluids

High glucose spills into the urine, drawing out water and minerals and causing high urine output at the beginning. This, along with possible vomiting, contributes to dehydration. Unless a person is able to drink enough fluids on their own, giving fluids through an intravenous line will be needed. It treats the dehydration and stops the formation of ketones.

Insulin

At the same time the fluids are given, an intravenous line with insulin in it will be started. The insulin will be directly dripped into the vein so it can act quickly to turn off ketone production and restore the body to normal. In some cases giving frequent insulin injections also works.

Potassium

This vital electrolyte is often depleted in DKA. Even if starting levels are high or normal, the potassium levels can fall, and this is very serious because adequate potassium levels are required for a normal heartbeat. Potassium is given intravenously or orally, or both.

Treating the cause

If there is an infection, such as a bladder infection or pneumonia, this needs to be treated. Older adults may be having a heart attack or other serious problem, so the team in the emergency room will need to carefully check out all the possible problems that can be happening at the same time.