How To Spot the Signs of Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is one of the most serious complications of diabetes. Symptoms can take you by surprise, coming on in 24 hours or less. It can be fatal without treatment, so it's important to know how to recognize it so you can respond quickly.

"Every minute that the person is not treated is [another] minute closer to death," said Joel Zonszein, MD, professor of medicine at Albert Einstein College of Medicine in New York City.

What Is Diabetic Ketoacidosis?

Diabetic ketoacidosis occurs when your body doesn't produce enough insulin. Diabetic ketoacidosis most often affects people with type 1 diabetes but can also occur with type 2 diabetes. Without insulin, sugar can't be stored in your cells to be used as energy and builds up in your blood instead. Your body has to go to a backup energy system: fat. In the process of breaking down fat for energy, your body releases fatty acids and acids called ketones.

Ketones are an alternative form of energy for the body, and just having them in your blood (ketosis) isn't necessarily harmful. Ketosis can happen when you go on a low-carb diet or even after fasting overnight.

"When I put people on a restricted diet, I can get an estimate of how vigorously they're pursuing it by the presence of ketones in the urine," said Gerald Bernstein, MD, an endocrinologist and coordinator of the Friedman Diabetes Program at Lenox Hill Hospital in New York City.

But too many ketones are a problem. "In individuals with diabetes who have no or low insulin production, there is an overproduction of ketones, and the kidneys can't get rid of them fast enough," said Dr. Zonszein. "Diabetic ketoacidosis occurs when so many ketones build up in the blood that it becomes acidic."

What Causes Diabetic Ketoacidosis?

In people with type 1 diabetes, diabetic ketoacidosis can be caused by skipping insulin either on purpose (say, because you felt you didn't eat enough) or accidentally (like if your insulin pump breaks). Diabetic ketoacidosis can also be caused by illnesses, namely pneumonia and urinary tract infections.

"If someone has a modest amount of insulin, but they are put under medical stress from an illness, then the body's stress mechanisms are going to push the glucose levels higher," said Dr. Bernstein, who is also past president of the American Diabetes Association.

Rarely certain drugs can cause diabetic ketoacidosis in people with either type 1 or type 2 diabetes.

Symptoms of Diabetic Ketoacidosis

Initial diabetic ketoacidosis signs include:

• Excessive thirst
• Frequent urination
• Dry mouth

In some cases, diabetic ketoacidosis might be the first sign you even have diabetes.

Late symptoms of diabetic ketoacidosis include:

• Nausea and vomiting
• Diarrhea
• Abdominal pain
• Trouble breathing
• Confusion or difficulty concentrating
• Loss of appetite
• Weakness
• Fruity smell on your breath

"Someone who gets diabetic ketoacidosis starts to feel weak, they start to vomit, they urinate a lot, and start to breathe very, very fast," said Dr. Zonszein. These are the body's attempts to compensate for the extra acid in the blood, Dr. Zonszein explained. "When they're vomiting, they're vomiting a lot of acid. They come in with acetone [a type of ketone] on their breath, which may give off the smell of a rotten apple."

Blood tests can reveal that people with diabetic ketoacidosis also have high blood sugar levels and high levels of ketones in their blood.

Diagnosing Diabetic Ketoacidosis

Since diabetic ketoacidosis happens when ketones build up to dangerous levels in your body, initial testing includes measuring the level of ketones in the body. Ketone test kits are available over the counter. It is recommended that if someone with diabetes has a blood sugar of 240 mg/dL or greater or is ill, they use an over-the-counter test kit to check ketone levels.

In a healthcare setting, a blood or urine test can be used to look for the presence of ketones. Other tests that may be done in the hospital include:

• Arterial blood gasses to assess the body's acid/base balance because those who are experiencing diabetic ketoacidosis may be in an acidic state
• Basic metabolic panel to assess things like electrolyte levels and kidney function
• Blood glucose testing to monitor how high or low blood sugar levels are
• Blood pressure monitoring to assess if blood pressure is too high or too low
• Osmolality blood test to assess the body's fluid balance

Treatment and Prevention

Diabetic ketoacidosis treatment consists of giving insulin and IV fluids and monitoring electrolyte levels. "The moment we make a diagnosis, we can start treatment," said Dr. Zonszein. Some people may need to be hospitalized; doctors will test your ketones, blood sugar, and electrolytes every few hours.

If you don't know you have diabetes, there's no way to prevent diabetic ketoacidosis. If you do know, you can take steps to stay healthy. Diabetes management is key. Here are a few tips for managing diabetes and avoiding diabetic ketoacidosis:

• Maintain a healthy diet by consuming fruits, vegetables, whole grains, and legumes.
• Avoid consuming a lot of refined carbs or sugar.
• Take any medications you use to manage your diabetes regularly, as advised by a healthcare provider.
• If you take insulin, ensure you take it as prescribed.
• Monitor your blood sugar regularly and especially when you get sick, as illness can cause fluctuations in blood sugar.

A Quick Review

Diabetic ketoacidosis is a serious complication of diabetes. Understanding the causes of the condition and symptoms is important, so you know what to look for. While managing diabetes can help prevent an episode of diabetic ketoacidosis, there are often situations, such as illness, that can make someone more likely to develop it.

If you recognize you are experiencing possible symptoms of diabetic ketoacidosis, it is important to seek medical care immediately.