Fear of DKA – what we know, what we don’t, and what we NEED to know

Now I had a slight knowledge of what DKA or Diabetic Ketoacidosis is, thanks in part to my being an Administrator of this site, but no REAL knowledge. So I set out to find what I didn’t know. I asked lots of my friends with diabetes, many of whom are T1’s. They either haven’t had a case of DKA or experienced it when they were young, at the time of diagnosis. I wanted to search out the facts, as there is such a fear related to DKA, and I wanted to truly know why.

WHAT WE KNOW:
“According to the Wikipedia entry,”… Diabetic ketoacidosis (DKA) is a life-threatening complication in patients with untreated diabetes mellitus (chronic high blood sugar or hyperglycemia). Near complete deficiency of insulin and elevated levels of certain stress hormones combine to cause DKA. DKA is characterized by hyperglycemia, acidosis, and high levels of circulating ketone bodies. Onset of DKA may be fairly rapid, often within 24 hours.

A key component of DKA is that there is no or very little circulating insulin so it occurs mainly (but not exclusively) in type 1 diabetes (because type 1 diabetes is characterized by a lack of insulin production in the pancreas). It is much less common in type 2 diabetes because the latter is closely related to cell insensitivity to insulin, not, at least initially, to shortage or absence of insulin. Some type 2 diabetics have lost their own insulin production and must take external insulin; they have some susceptibility to DKA, somewhat like Type 1s.

What are the signs and symptoms of DKA?
The symptoms to watch for are not always obvious. They can start slowly and can be mistaken for other illnesses. Often toddlers do not show the classic signs of DKA.

Early signs:
• Feeling tired or fatigued
• Excessive thirst and/or excessive urination
• Signs of dehydration such as dry mouth
Later signs:
• Nausea/vomiting
• Abdominal pain
• Confusion
• Rapid, deep, labored breathing (Kussmaul's respirations)
• Breath that smells fruity
• Fever
• Unconsciousness

WHAT WE DON’T KNOW:
What damage can be incurred by DKA? Renal failure, chronic heart failure, and respiratory distress can happen due to DKA. Even after someone has survived DKA, the resulting damage can be extensive. The long term damage can inflict the value of life as we know it. “It is the metabolic acidosis that pushes you into respiratory distress and is what can kill you,” according to Holly Brewer, MS RD CDE

WHAT WE NEED TO KNOW:
I spoke with my good friend, Dr. Michael B. Davidson, who is an Endocrinologist in New Hampshire, he gave me this analogy: “Starvation in a time of plenty. Insulin is the key that lets glucose into cells, if you have no insulin, the cells think they are starving. When insulin binds to the surface of the cells, little channels open up to let the glucose move from the blood to the cells. When there is no insulin, there is a lot of sugar in the blood stream, but the cells are blind to it. Your body’s response it to try to find MORE glucose. Glucagon, and other ‘stress hormones’ are released and tell the liver to break down storage glucose (glycogen) and to make new glucose (gluconeogenesis). When the liver makes new glucose, it needs building blocks. One of the important building blocks comes from the breakdown of triglycerides. The liver uses glycerol to make glucose, but the remaining part of the triglyceride breakdown becomes ketone bodies. All of these factors act as a vicious cycle to worsen DKA.”

One of the ways that DKA is becoming recurrent, that I learned while doing the research for this article was insulin manipulation. We are seeing more cases of DKA in women now more than ever before. Taking less insulin so as to lose weight, which is truly an eating disorder in type 1 diabetics, it is known as "diabulimia," Women with eating disorders and diabetes typically struggle with symptoms similar to those of women with eating disorders who do not have diabetes. However, they exhibit a very dangerous symptom of calorie purging in the form of insulin restriction. This was something I was quite unaware of, it is very scary to know that someone may be “starving” their bodies of insulin. I’m sure a lot of people have never heard of this condition.

How to be on the lookout for DKA:
Testing of ketones MUST be done:
• Anytime your blood glucose is over 250 mg/dl for two tests in a row.
• When you are ill. Often illness, infections, or injuries will cause sudden high blood glucose and this is an especially important time to check for ketones.
• When you are planning to exercise and the blood glucose is over 250 mg/dl.
• If you are pregnant, you should test for ketones each morning before breakfast and any time the blood glucose is over 250 mg/dl.

Call your diabetes educator or physician, as you may need additional insulin. Drink plenty of water and fluids containing no calories to "wash out" the ketones. Continue testing your blood glucose every 3 - 4 hours, testing for ketones if the blood glucose is over 250 mg/dl. Do not exercise if your blood glucose is over 250 mg/dl and ketones are present.

Have you had DKA? What has been your experience? What can you share that will help others?

Tags: DKA, diabeticketoacidosis

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I've had T1 diabetes for 24 years and only had a bout with DKA in December 2007 (exactly one week before Christmas). Here's my experience.

My wife got the stomach flu over the weekend and since it is the gift that keeps on giving, I got it from her. On Monday afternoon, I started to feel run down and kind of "squishy". By Tuesday morning, I was vomiting. I have not vomited like this for quite some time. I could not even keep water down. Since I wasn't eating, I didn't take any insulin (I didn't want to go low and then try to bring it back up when I couldn't keep food or liquids in my stomach). Wrong decision. The stress of the illness, lack of insulin and then the dehydration from the stomach flu all added up to DKA for me.

This is something that I NEVER want to experience again. By 5 p.m. on Tuesday evening I was in major pain. I could not get comfortable (between bouts of vomiting about every hour). I felt like I could crawl out of my skin! My wife finally convinced me to go to the hospital when she couldn't get a BS reading on my glucometer (remember, I'm a stubborn man who doesn't like doctors and hospitals). I was in so much distress, I said yes.

After the 5 minute drive to the hospital, I told her she would need to go in and get a wheelchair, because I was so weak I couldn't walk. By this time, my thirst was unquenchable! It was horrible. After waiting only a few minutes to get into the exam room, I started having horrible abdominal cramps. My temperature was so low, it wouldn't register on the thermometer (we found out later I was down to 94 degrees). When ER staff couldn't get a blood sugar reading on the glucometer, they got worried and started moving fast (found out later I had a blood sugar of 800). I was so dehydrated they had a horrible time getting an IV started (I ended up with 3 IVs with one of them surgically implanted into my neck).

The doctors were most concerned about my abdominal cramps. They were not very familiar with the abdominal pains in DKA. During the two hours I was the ER, I had HORRIBLE pain that Morphine wouldn't touch. They finally got me in ICU and I ended up with x-rays and a CT scan just to make sure I didn't have any abdominal blockage, etc.

I spent two days in ICU and then two more days in the regular hospital floor. I was weak as a kitten for about a week after I got out of the hospital.

Needless to say, we have a new rule in our house. If I vomit more than 3 times, it is off to the doctor. I also have become insane about checking my blood sugar and I'm just waiting on insurance approval for my insulin pump.
Wow! Thanks for writing this. I learned some new things.

My only experience of DKA was at diagnosis (so I'm not sure how this differs from other experiences). I had the symptoms of diabetes for months, but ignored them (and actually thought it was either depression or cancer).

I just wanted to add one symptom to you list above, which was actually my MOST disturbing one. I had extremely painful LEG CRAMPS. To the point that they woke me up during the night and I had to get up and walk around to try to relieve the pain. I let this go on every night for about a month.

Apparently these cramps were due to a lack of certain minerals (potassium??). In the hospital, I had to drink these shakes to replenish the missing minerals. The nurses warned me that they tasted horrible, but I thought it was the most delicious thing! I guess my body was craving something!

I went to the ER when I woke up vomiting and felt like I was about to black out.
Kristin:

Yes, a deficiency in potassium is one of the results of DKA and a cause of leg cramps (we call them charlie horses) in the middle of the night.

During my recovery in the hospital I had to drink several drinks of potassium stuff (tasted like really strong Gatorade).
I had to have IV potassium, which felt like hot metal running the length of my vein. Never again!!
Same here, before I was diagnosed I had some really bad leg cramps. After my sugars normalized they just went away. And my feet would swell in hot weather until my ankles pretty much disappeared.

Add the huge ketones, weight loss and the funny tingling in my feet at that time and I really wonder how much damage that did to my organs and how much damage I could have prevented if I had just gotten myself to the doctor earlier. I knew something was off at least two weeks before I went to see him.

Kat
argh. reading about dka (which i knew was very serious) just made me VERY uncomfortable. i have been in dka once - - - when i was diagnosed. here's the story. it ain't pretty, but i'm doing well considering.

my father had fallen off of the roof clearing leaves and had had surgery to repair his broken ankle. he did very well during the surgery and came home a few days afterward (in time for christmas:-). about 11:30 pm on the night of 2 january 06, my mom called me to say that my dad was very sick ("heartburn" he said), but he didn't want to go to the hospital. i went over there, took him some tums, and sat down to talk to them. he was on the phone with the doctor chatting away when he dropped the phone. i called 911 and started cpr, but he didn't make it.
i remember being extremely thirsty between the time i stopped cpr and the emts took over, but it had been really hard to do cpr on my dad as he was in a recliner and not a petite guy (6'2", 180).
we had followed the ambulance to the hospital, and when we left the hospital, i noticed that i felt every breath going into my lungs. of course, i blamed it on the "night air". soon after we got back to my parents' house, my sister jane came in. we all tried to go to bed, but i couldn't sleep. i vomited what seemed like buckets, but i thought it was because my father had just died in front of me. when my other sister pat and her husband came in, they didn't like the way i looked. they both tried to find a pulse on me, and my sister just found one that was thready. they insisted on taking me to the hospital and i am so glad they did.
my blood sugar was 560 and i was in dka. i also had an aspiration pneumonia (i had inhaled vomit into my lungs) and tako tsubo syndrome. apparently when papa went into cardiac arrest/respiratory distress, my system was flooded with adrenaline. it fried everything. tako tsubo syndrome is also called "broken heart syndrome" because it usually happens to post menopausal women who are grieving or under severe stress. i am considered a type 1 diabetic, although i would suspect that i was pretty close to being diabetic if not one already when this episode happened. i am thankful everday that i'm in houston with a cracker jack team of doctors who figured things out quickly. tako tsubo typically looks like a heart attack, but it is not. it is simply treated with beta blockers (praise be). i spent 8 days in the hospital - - - 6 in ccu (intubated, central line, the whole enchilada). not only was i dealing with the diagnosis of diabetes, but also the death of my father. i feel extremely lucky to still be here as i was told after i got out of the hospital that doctors had given me a 30% chance of surviving. my endo even told me that he had been called in as a "courtesy" because they didn't expect me to be "living" with diabetes.

my advice for avoiding dka?
be as on top of your bs as much as possible. if something doesn't feel right, get your booty to your doc or to the e.r. drink lots of water. pay attention to the warning signs. i believe i saw a blog post of someone who said that if you can keep from throwing up and get your sugar down, half the battle is won (please remember i'm NOT a doctor, nor do i look like one:-).

here are the signs i had
• feeling tired or fatigued
• excessive thirst and/or excessive urination
• signs of dehydration such as dry mouth
• nausea/vomiting
• abdominal pain
• confusion
• rapid, deep, labored breathing (Kussmaul's respirations)
• breath that smells fruity
• fever
• unconsciousness

my story is sad. the wee hours of 3 january 07 truly changed my life, but i'm healthy and happy and LIVING with diabetes. sigh.
Wow, what a story.

I can't imagine how you coped with so much. But the fact that you are a "healthy and happy and LIVING with diabetes" is an inspiration.
Thanks for this essential information. DKA has always been a mysterious animal to me.

I've had two or three bouts with it - in hindsight - none requiring a hospital visit. They all came after turning off my pump before some vigorous exercise and the all showed up about two hours after I started. Because insulin peaks in about two hours and I ran a long distance with my pump off - two hours later I had no insulin.

Symptoms - light headed, muscle aches in shoulders, arms and thighs, weakness, stomach ache, nausea. Like a bad flu.

Bed rest and lots and lots of water helped me. I don't turn off my pump now and I've had no recurrences. But I know what to watch for.

Thanks again for the informative posting and responses.

Terry
I've been a Type 1 for 35 years and with not too good control at the times it happened been through my share of DKA! and hadn't even relized what it was!What you've posted has told everybody about all I can about DKA1 I know I don't want to have to go through it again if I don't have too! HA!
DKA happens, the "trick" is not letting it happen twice (ie find out you are in DKA... and then stop it in its tracks ASAP).

I had episodes as a kid back in the "dark ages" when I was sick with flu, colds, etc. Had them when I was sick since then every so often as well.

The worst DKA episodes I ever encountered was when I used a pump . My body apparently got used to the basal-background short acting insulin. Any time I disconnected, for even a single hour.... BANG... DKA for Stuart

Had serious problems with delivery, infusion sets not working... proof, DKA. Not daily at all but at minimum once a week several times a month versus if I badly got sick maybe, maybe once a year, if that, .

No more pump, no more DKA espsodes

Stuart
The one and only DKA experience I have had was when first diagnosed. That was limited to having an unquenchable thirst and of course going to the bathroom constantly, other than that I felt fine. Well I would get very tired after eating.

In the ER they had told me I was close to the vomiting stage. I spent two days in the ICU as that was where they could give me an insulin drip, followed by a one day stay in the regular part of the hostpital and then sent home
Wow! I have never had an experience with DKA! and after reading all of these post I hope I never will have to deal with it. Thank you for posting your finding's, I diff learned something.

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