Facts about DKA: An Interview with Emergency Medicine Specialist

Leah Hatfield, PharmaD, BCPS, a lead clinical pharmacist specialist in Emergency Medicine at University of North Carolina, Chapel Hill, recently talked with Beyond Type 1 about diabetic ketoacidosis—DKA—the dreaded term that we who have experienced elevated blood sugars all hope never to hear.

Leah specializes in emergency medicine at the University of North Carolina Medical Center. She describes her encounters with DKA and provides some myth-busting guidance on how all of us living with type 1 can approach the condition.

What is DKA?

Diabetic ketoacidosis (DKA) is a complication from diabetes that can be serious and life-threatening. DKA is often a common factor when first diagnosed with type 1 diabetes, but also can occur during management of the disease. When the body is not receiving enough insulin to break down glucose, it forces the body to start breaking down fat as fuel. Ketones are then released into the body.

What happens to your body?

Diabetic ketoacidosis is a condition that causes changes in body chemistry. Leah sees dangerous physiological symptoms in patients with blood sugars up to 55.6 mmol/L1,000 mg/dL.

“When a blood sugar gets that high, you get what’s called osmotic or osmolar changes within the body. What that means, chemically, is the body has such a high percentage of glucose in the blood that you’re going to begin to lose a lot of fluid. The blood glucose will be very, very high, but because of all that extra urine output, the patient will dehydrate very quickly.

“These fluid and electrolyte disturbances in the body can happen in the span of just a few hours for someone that has an extremely elevated blood glucose.”

Myth: Only severe hyperglycemia causes DKA.

“DKA patients can present with very mildly elevated blood glucose, sometimes only in the 13.9 to 16.6 mmol/L250 to 300 [mg/dL] range,” Leah says, “Other times, over 44.4 mmol/L800 mg/dL, even over 55.6 mmol/L1,000 mg/dL in rare cases. We sometimes see DKA at the initial diagnosis [of type 1 diabetes] in our adolescent and teenage population.”

Myth: The presence of ketones is the only symptom of DKA.

At the UNC’s 900-bed hospital, Leah sees about one patient in DKA every day.

“Often, our patients that present in DKA are febrile—they have fevers. They often have abdominal pain, nausea, vomiting and other symptoms of an infection. These can occur along with all of the electrolyte disturbances that happen with DKA.

“In some cases, if it’s a more moderate to severe DKA, they might even have altered mental status, so they might be confused, they might have a decreased level of consciousness. In the worst case scenario, they might even present comatose.”

Myth: DKA is the result of uncontrolled blood sugar levels.

“The most common cause, by far, is that the patient is  sick. They’ve gotten an infection or the flu that’s offset their normal body rhythms and routines. It can also happen during a period of acute stress. For a person with type 1 diabetes, those can be enough to cause an episode of DKA.”

Fact: Patients might not realize they are in DKA.

“I think type 1 diabetes, in particular, is very insidious or sneaky in its onset,” Leah says.

“When we look at people with type 1 diabetes, they’re often young, healthy patients, they don’t have a lot of other medical history, and so they have these very benign signs and symptoms that can go on for weeks to months. Most often, they’re more thirsty than they used to be, or they’re  more hungry than they used to be and urinate more often.”

Fact: DKA can be fatal.

DKA is dangerous and can be fatal for several reasons, Leah says.

“[One of] the most common causes of death related to diabetic ketoacidosis is hypokalemia, which is potassium being too low. If we don’t replace that potassium fast enough or if we give too much insulin without giving potassium, the potassium can fall too low. What that typically causes is a disturbance in the rhythm of the heart that then can cause cardiac arrest.

“The other potential cause of death for a DKA patient would be hypoglycemia. If we decreased the blood glucose too fast, we actually could cause a patient to die from hypoglycemia.

If these patients stayed at home and they lost consciousness and no one found them, you can certainly die from hyperglycemia from DKA at home. It would usually be loss of consciousness, followed by a cardiac arrest. We do see that sometimes, unfortunately, still.”

Fact: Awareness saves lives.

“We teach a lot of our type 1 diabetics here to watch for warning signs: If they feel signs and symptoms of a cold or an illness coming on, check their blood glucose more frequently. A lot of our patients will know because they have higher than normal blood glucose all of the sudden and they’ll be like, This is strange, what’s going on?

“Sometimes they’ll even have what we call a prodrome for a day or two: they won’t feel quite right and they’ll start having signs and symptoms of just feeling kind of crummy, and then they’ll notice that their blood sugars are starting to trend up, and their insulin requirements are changing when they’ve been stable for a long time. Then, all of a sudden, they’ll feel very sick.”

Myth: Insulin is the first line of treatment for DKA.

“A lot of people think that the first thing we’re going to do is give the patient insulin and that’s actually not the first thing that we do,” says Leah. First, the fluid and electrolyte disturbances are corrected.

“We’re usually going to be placing large IVs very quickly and starting what we call ‘massive volume resuscitation,’ or massive replacement of fluids. This replaces what we call extravascular volume, so it puts the fluid in the body back in the right place. It primes the body to be more sensitive and more receptive to insulin when we  give it.”

“The next step is insulin. What studies [have shown us] over many years is one of the best ways to give that insulin is by an IV drip. We run it at a very low dose, a dose based on body weight.”

Fact: Too much insulin, too soon, can be dangerous for the patient.

“It’s important for us to be thoughtful about the right time to give insulin. Insulin causes potassium and electrolytes in the blood to shift back inside the cells. Most patients with DKA have very large deficits of potassium in their body to begin with, so if we were to give them insulin too early, we could unintentionally cause more problems.

“We want their blood glucose to come down, but we want it to come down slowly.

[That seems] kind of counterintuitive. Most people think, Well, gosh, if my blood glucose is 900, I want to get it back down to 150 as soon as I can.

“Any time we alter the amount of glucose in the blood, it’s going to alter how fluid shifts in the body. So, if we decrease the blood glucose too fast, it causes a complication called cerebral edema. What that means is all this fluid rushes back into the body and it all rushes into the brain.

“Our goal for DKA patients is to reduce their blood glucose by about  5.5 mmol/L100 mg/dL each hour. If they come in with a blood glucose of 44.4 mmol/L800 mg/dL, we’re  looking at several hours before we correct them back to a value that’s more normal—six to eight hours. We don’t want correct it too quickly.”

Fact: Close monitoring is critical for patients with DKA.

“We’re going to keep checking their blood glucose every hour, and what we’re watching for is that decrease of 5.5 mmol/L100 mg/dL in their blood glucose value per hour. If it’s falling too quickly, we’re going to slow down the insulin, or if it’s not coming down quickly enough, we might give them more fluid or we might speed up the insulin a little bit, but it’s followed very closely.”

Fact: DKA treatment in the United States can be expensive.

“Most DKA admissions, this day and age, are not in the hospital more than  24-48 hours, we’re able to correct them pretty quickly and de-escalate their care pretty quickly,” Leah says. That hospital stay, however, can add up.

“It’s going to vary somewhat from institution to institution based on the level of care required, but it can easily cost over $10,000 just for a one day admission.”

The research appears to agree: A 2013 study published in Pediatrics looked at five years’ worth of DKA admission information from 38 U.S. hospitals. The study found that among 24,890 hospital admissions for DKA among children ages 2-18, the mean length of stay was 2.5 days and the total cost ranged from $4,125 to $11,916.

Fact: DKA can be caught early or prevented.

“A blood glucose test isn’t particularly expensive. Here in the hospital, we do them routinely, all day long, even for kids that we don’t think might have [DKA] going on.”

“[People with diabetes] can test for ketones themselves at home. They can buy keto sticks and they can test their urine at home. We teach our type 1 patients: if you’re not feeling well, go to your doctor and get checked out, check your blood glucose yourself more frequently, look for ketones in your urine. Or if you’re having difficulty eating and drinking, come see us and let us help you with staying hydrated before you get to the point that you’re in severe DKA.”