- Insulin is the primary hormone responsible for modulating blood sugar within the normal range to facilitate various physiologic functions. Severe Insulin deficiency results in a life-threatening syndrome called Diabetic Ketoacidosis, in which low Insulin levels are
seen, together with increased Glucagon and growth
- This combination results in the breakdown of fat, called lipolysis, followed by the production of ketones. Elevated ketones, Glucagon, and growth
hormone stimulate the liver to produce ketones (called
hepatic ketogenesis), further exacerbating ketoacidosis.
- Ketoacidosis describes a cycle of wildly unmodulated blood sugar levels. It usually occurs in Type I (Insulin dependent/Insulin deficient) diabetes, and may also occur in Type II diabetes (Insulin resistant or
decreased Insulin production) under extreme conditions, such as infection or trauma.
- Severe thirst
- Frequent and large urination
- Breath may have a fruity odor
- Mild abdominal tenderness may be present
- Tachycardia (elevated heart rate)
- Orthostatic Hypotension (blood pressure drops on standing)
- Blood -- elevated blood sugar
greater than 250 milligrams in 100 milliliters of blood =
250 mg/dL (may be much higher), elevated blood acetone and beta-hydroxybutyric acid (the latter must be specifically tested for), low plasma bicarbonate level, low arterial blood pH, blood urea nitrogen/creatinine often is elevated due to Dehydration; triglycerides often elevated
- Amylase may be elevated due to increase in salivary Amylase (so not clinically significant) or due to pancreatitis (which can be life-threatening). Therefore, if the Amylase is elevated, Lipase should also be checked (elevated Lipase indicates pancreatitis).
- Potassium level initially may be quite elevated, but often becomes very low from treatment
- Phosphorus levels often drop with treatment, but need to be treated only if severe
- Liver function tests should be checked to rule out Cholecystitis
- White blood cell count may be elevated with or without an infection
- Urine will show high glucose and high ketones
- Urinalysis should be checked for signs of infection
- Poorly controlled diabetes
- Sepsis (infection)
- Insulin pump therapy (1 in 80 persons who use an Insulin pump develops DKA)
- Intravenous hydration, usually initially with boluses of normal saline. As the Potassium level in the blood declines, it is often added to intravenous fluids. If the blood sugars normalize, but ketones remain present (high), intravenous fluids with glucose are begun and continued with the Insulin drip.
- Intravenous Insulin bolus, followed by intravenous Insulin drip.
The dosage of insulin will be determined by the serum blood
sugar and the degree of acidosis.
- Bicarbonate solutions are usually only considered if the arterial blood pH is below 7.10 (acidotic)
replacement only if severely (cautiously, because it may precipitate Calcium in tissues and cause tetany)
- Blood sugar goal should be 200-300 mg/dL for 24 hours after ketoacidosis is corrected
- Careful monitoring and control of blood sugars
- Dietary compliance
- Fluid replacement with slightly
emergency medical treatment. This is a life-threatening
illness that may result in permanent kidney damage, brain
injury, or death.
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