Diabetic Ketoacidosis (DKA)
Diabetic Ketoacidosis (DKA): Comprehensive Overview
Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes caused by severe insulin deficiency, leading to hyperglycemia, ketosis, and metabolic acidosis. It primarily affects individuals with type 1 diabetes but can also occur in type 2 diabetes under certain conditions.
Causes of DKA
- Insulin Deficiency:
- Absolute deficiency (type 1 diabetes) or relative deficiency (type 2 diabetes during severe stress).
- Triggers include missed insulin doses, infections (e.g., pneumonia, UTIs), pancreatitis, or trauma.
- Counterregulatory Hormones:
- Excess glucagon, cortisol, and catecholamines promote lipolysis and ketogenesis.
Symptoms
Symptoms develop over hours to days and progress in severity:
| Early Signs | Advanced Signs |
|---|---|
| Excessive thirst, frequent urination | Fruity breath (acetone odor) |
| Fatigue, dry mouth | Kussmaul breathing (rapid, deep breaths) |
| Nausea, vomiting, abdominal pain | Confusion, lethargy, or coma |
| Blood glucose >250 mg/dL | Hypotension, tachycardia |
Note: Children may present with acute cerebral edema (headache, altered consciousness, seizures).
Pathophysiology
- Hyperglycemia: Insulin deficiency prevents glucose uptake, causing osmotic diuresis (fluid/electrolyte loss).
- Ketogenesis: Uncontrolled lipolysis → fatty acids metabolized into ketones (beta-hydroxybutyrate, acetoacetate).
- Metabolic Acidosis: Ketones lower blood pH (<7.3), leading to anion gap acidosis.
Diagnosis
Diagnostic criteria include:
- Hyperglycemia: Blood glucose >250 mg/dL.
- Ketosis: Elevated serum/urine ketones.
- Acidosis: Arterial pH <7.3, serum bicarbonate <18 mEq/L.
- Anion Gap: >12 mEq/L.
Additional Tests:
- Electrolytes (watch for hypokalemia), renal function, infection markers.
Treatment
Immediate management focuses on fluid resuscitation, insulin therapy, and electrolyte replacement:
- Fluids:
- Isotonic saline (1–2 L over 1–2 hours) to restore intravascular volume.
- Switch to hypotonic fluids (e.g., 0.45% saline) once blood glucose reaches ~200 mg/dL.
- Insulin:
- IV continuous infusion (0.1 units/kg/hour) to suppress ketogenesis.
- Transition to subcutaneous insulin once acidosis resolves.
- Electrolytes:
- Potassium: Monitor closely (risk of hypokalemia from insulin therapy).
- Bicarbonate: Reserved for severe acidosis (pH <6.9).
Complications
- Cerebral Edema:
- Most common in children; symptoms include headache, coma, respiratory arrest.
- Mortality: ~20–25% if untreated.
- Hypokalemia: Arrhythmias, muscle weakness.
- Hypoglycemia: From aggressive insulin therapy.
Prevention
- Regular glucose/ketone monitoring during illness or stress.
- Sick-day management: Adjust insulin doses, stay hydrated, and seek care if ketones rise.
- Education: Recognize early symptoms (thirst, polyuria) and avoid insulin omission.
Key Statistics
- Mortality rate: <5% with prompt treatment; up to 50% if untreated.
- 25–50% of DKA cases occur in newly diagnosed type 1 diabetes patients.
When to Seek Emergency Care:
- Persistent vomiting, confusion, rapid breathing, or blood glucose >300 mg/dL with ketones.
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