What is Adult Diabetic Ketoacidosis?

Diabetic ketoacidosis, or DKA, is a dangerous condition that can occur in people with diabetes. It’s marked by high blood sugar levels, acidity in the body, and presence of ketones (a type of acid) in the blood. DKA is commonly seen in people with type-1 diabetes, but it can happen in type-2 diabetes patients as well. Usually, DKA is triggered by diabetes that has just been diagnosed, an infection, or when the patient does not follow their treatment plan correctly.

What Causes Adult Diabetic Ketoacidosis?

Diabetic ketoacidosis, or DKA, is a condition more typically seen in individuals with type 1 diabetes, but it can also happen to those with type 2 diabetes. This condition often happens when someone is going through a stressful health event, like an injury, surgery, or infection. It can also be triggered by not taking diabetes medications properly, newly diagnosed diabetes, or other acute health issues. Infections such as pneumonia and urinary tract infections are common triggers. Other triggers can include alcohol abuse, physical injury, a blockage in the lungs (pulmonary embolism), or a heart attack.

There are also certain medications that can increase the chances of developing DKA, such as corticosteroids, thiazides, sympathomimetic agents, and pentamidine, as these can interfere with how the body uses carbohydrates. Certain antipsychotic drugs can also raise blood sugar levels and in rare cases can lead to DKA.

Certain medications used to treat diabetes, called SGLT2 inhibitors, can also lead to DKA. This is because when SGLT2 inhibitors are taken alongside insulin, the dose of insulin is often reduced to prevent low blood sugar, but this lower dose might not be enough to prevent the breakdown of fat into ketones, causing DKA. SGLT2 inhibitors can also increase the levels of a hormone called glucagon, leading to an increase in ketones, higher blood sugar levels, and DKA. Interestingly, a small group of people may experience DKA without the typical high blood sugar levels, a condition known as “euglycemic DKA”.

One of the main reasons for repeated DKA cases, especially in lower-income urban areas in the US, is not taking insulin as prescribed. Issues such as low education levels and financial constraints can interfere with people sticking to their prescribed medication schedules. A recent study even found that cocaine use is a independent risk factor for recurring DKA.

Risk Factors and Frequency for Adult Diabetic Ketoacidosis

Diabetic ketoacidosis, or DKA, can vary a lot in how often it occurs. The incidence rate can range from none, to 56 instances per 1000 people each year, with these rates fluctuating depending on where in the world you are. Women and non-Whites are more likely to experience DKA, as are patients who have to inject their insulin, as opposed to those who use insulin infusion pumps.

DKA rates in children vary widely by country. Nigeria has the lowest rates—approximately 2.9 cases per 100,000 children.
In contrast, the highest rates are in Sweden and Finland where the incidence is 41.0 and 37.4 per 100,000 children respectively.
About 0.7% of DKA cases in the United States occur in nursing homes.
Unfortunately, mortality rates tend to be higher in the elderly and people with serious concurrent illnesses.

Old age, being in a coma, low blood pressure and severe comorbidities are all factors that can worsen DKA. Additionally, in urban Black patients, not adhering to insulin treatments, likely as a result of substance abuse, is the primary cause of DKA. Obesity is also common in this patient group, particularly if they have recently been diagnosed with diabetes. However, educating patients and improving access to healthcare can help alleviate these DKA emergencies.

Despite its severity, DKA is preventable. It’s a serious complication of diabetes, and data from the CDC’s United States Diabetes Surveillance System shows growning hospitalisation rates for DKA from 2009 to 2014, especially in those less than 45 years old. But there’s a silver lining: mortality rates due to hyperglycemic crisis among adults with diabetes have been falling in the U.S. However, there’s still work to do. Death rates among Black men and deaths occurring at home need to be further reduced.

The elderly are particularly susceptible to DKA. This is due to increased resistance to insulin and less of a thirst mechanism as we age. Both lead to hyperglycemia and dehydration—two key triggers of hyperglycemic emergencies. However, increased vigilance for diabetes and early aggressive treatment of high blood sugar and its complications can significantly cut both the morbidity and mortality from DKA in older people.

Signs and Symptoms of Adult Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is a serious condition that can cause numerous symptoms and physical changes in patients. People with DKA might eat more than usual, urinate excessively, or feel extremely thirsty (symptoms of high blood sugar levels). As dehydration sets in from fluid loss, patients may notice decreased sweating, a dry mouth, and less urine output. Other symptoms include lack of appetite, nausea, stomach pain, vomiting, and weight loss.

If an infection triggers DKA, the affected person may experience symptoms such as a fever, cough, or problems related to urination. People with developing brain swelling (cerebral edema) might also experience headaches or confusion. A person’s medication history, including what drugs they take and how they use them, as well as their use of substances like alcohol or drugs, should be checked.

Eating more than usual (polyphagia)
Excessive urination (polyuria)
Extreme thirst (polydipsia)
Less sweating
Dry mouth
Decreased urine output
Lack of appetite
Nausea
Stomach pain
Vomiting
Weight loss
Fever

On physical examination, patients with DKA typically have an increased heart rate (tachycardia) and rapid breathing (tachypnea). A fever or unusually low body temperature may be present if an infection triggers the DKA. Their blood pressure might change, and they could have low blood pressure in serious cases. Patients may look unwell and breathe rapidly and deeply (a symptom known as Kussmaul breathing). Sometimes, their breath might have a fruity smell because of the presence of a chemical called acetone. Signs of dehydration, such as slow blood refill in the capillaries, poor skin elasticity, and dry mucous membranes, might also appear. Abdominal tenderness and an altered mental status might occur in severe conditions, emphasizing the need for immediate attention.

Testing for Adult Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) diagnosis usually includes certain criteria. The blood glucose should be higher than 250 mg/dl, the pH of artery blood less than 7.3, the level of bicarbonate in serum less than 15 mEq/l, and presence of ketones in blood or urine. Anion gap, which is normally 12 mEq/l, would be more than 14-15 mEq/l indicating there’s too much acid in the blood. pH and blood glucose might be normal in some cases due to other conditions or medications.

Most DKA patients in hospitals show high white blood cell count, or leukocytosis. Sodium reported in lab tests tends to be incorrectly low in DKA. To correct this, add 1.6 mEq to the measured sodium for every 100 mg/dl of glucose above 100 mg/dl. Measured potassium is usually high too, however, insulin can cause it to decrease quickly. Magnesium is often low and requires replenishment. Tests may show high phosphate levels, but the body might still be lacking this mineral.

Other tests including cultures of urine, sputum, and blood, chest radiograph, and serum lipase might also be required based on each case. Pneumonia and urinary tract infections are most commonly seen in DKA patients. An A1C test, which shows glucose trends over several months, would also be useful.

During DKA, ketone body ratio (3-beta-hydroxybutyrate to acetoacetate) can rise from 1:1 to up to 10:1. Ketone levels can be measured by a semi-quantitative test, but it gives only an approximate and may show false positives. Newer, cheaper tests can provide more accurate results.

DKA affects carbohydrate metabolism, which can cause increased pancreatic enzyme levels, but having these symptoms doesn’t necessarily mean acute pancreatitis. Imaging like CT scan can help distinguish between DKA and acute pancreatitis. Lipid derangement, or abnormal fat levels, are also common in DKA patients. Insulin treatment usually helps lower these levels in a day.

An ECG can show if there are changes related to lack of oxygen supply to the heart, or symptoms related to low or high potassium levels. For imaging, a chest x-ray can check for lung issues and CT or MRI of the head can detect brain swelling, however, treatment should not be delayed if this is suspected.

Treatment Options for Adult Diabetic Ketoacidosis

Managing diabetic ketoacidosis typically involves four key elements: restoring and maintaining fluid levels, administering insulin, replacing electrolytes, and providing supportive care.

Hydration:

Dehydration is a common issue in people with diabetic ketoacidosis and immediate restoration of fluid levels is crucial. This helps to counteract low blood volume, promotes general tissue health, and aids in removing harmful ketones from the body. Hydrating also supports sugar level control alongside insulin therapy.

Choice of Fluids and Infusion Rate:

Isotonic fluids, especially normal saline, are often used as they’ve been shown to be effective. Alternative solutions such as Ringer lactate might pose a risk of causing metabolic acidosis. The rate at which fluids are given typically starts aggressively, but is then adjusted according to patient’s reaction and needs. It’s important at this stage to avoid the risk of cerebral edema, or brain swelling, which can arise with aggressive fluid administration.

Insulin Therapy:

Intravenous insulin is commonly used, and its usage has greatly reduced deaths associated with diabetic ketoacidosis. Initial doses are typically higher, but are then tapered down as blood sugar levels decrease. Once the patient’s condition improves and diabetic ketoacidosis resolves, insulin can then be administered subcutaneously, or under the skin.

Electrolyte Replacement:

Patients with diabetic ketoacidosis usually need potassium and sometimes magnesium supplementation as both levels tend to decrease with appropriate treatment. However, supplementation of other electrolytes such as bicarbonate and phosphate is usually not necessary, unless the patient’s levels are extremely low.

Maintenance and Monitoring:

Maintaining hydration and appropriate electrolyte levels is dependent on the patient’s stability. It’s also important to keep a close eye on blood sugar levels and other important indicators such as blood gases and blood urea nitrogen. Careful monitoring of the patient’s mental status and neurologic state is important, as changes can be indicative of brain swelling, a serious complication of diabetic ketoacidosis.

Managing Complications:

It’s generally best to avoid intubation and the use of a ventilator whenever possible, due to several associated risks. If used, it’s important to maintain appropriate ventilation to avoid making the acidosis worse. However, in cases where patients are unable to compensate for their acidosis due to their inability to breath appropriately, intubation becomes necessary.

Underlying or precipitating causes (like infection) of diabetic ketoacidosis should also be treated to ensure a full recovery from the condition.

When a patient presents with symptoms that suggest diabetic ketoacidosis, it’s possible they might actually have a different medical condition. Due to the varied ways diabetic ketoacidosis can appear clinically, it can mimic or resemble other health conditions. This is why healthcare providers need to think about other possible diagnoses when they suspect diabetic ketoacidosis. Here’s a brief list of possible differential diagnoses:

Hyperosmolar hyperglycemic nonketotic syndrome (another diabetes-related complication)
Starvation ketosis (when the body produces ketones due to lack of food)
Myocardial infarction (commonly known as a heart attack)
Pancreatitis (inflammation of the pancreas)
Alcoholic ketoacidosis (excessive alcohol consumption leading to body producing ketones)
Lactic acidosis (too much lactic acid in the body)
Sepsis (a severe response to infection)
Exposure to toxins like ethylene glycol, methanol, paraldehyde, salicylate
Overdose on medication for diabetes
Uremia (accumulation of waste products in the blood due to kidney failure)

Each of these conditions can present with symptoms similar to diabetic ketoacidosis, so it is crucial for healthcare providers to consider them and perform the necessary tests to make the correct diagnosis.

What to expect with Adult Diabetic Ketoacidosis

In developing countries, diabetic ketoacidosis (a serious diabetes complication) still has a death rate between 0.2% and 2.5%. The most serious cases occur in patients who are comatose, have low body temperature, or are producing an abnormally small amount of urine. However, if the condition is treated quickly, the results are generally positive, especially if it was not triggered by an infection.

The situation can be more complex for elderly patients with additional health problems like heart attack, pneumonia, or sepsis. These patients often have long hospital stays and a higher risk of death.

Cerebral edema, a condition involving swelling in the brain, is the main cause of death from diabetic ketoacidosis. This condition mainly affects younger patients and is primarily caused by shifts within the cells. Also, kidney dysfunction poses a significant health concern.

A recent study highlighted that among patients with type-2 diabetes who experience diabetic ketoacidosis, there is a high risk of stroke in the first six months following the event.

Possible Complications When Diagnosed with Adult Diabetic Ketoacidosis

One of the common complications while treating diabetic ketoacidosis (DKA) is low blood sugar levels (hypoglycemia), occurring in roughly 5-25% of patients. It can lead to serious issues like seizures, abnormal heart rhythms, and cardiovascular events. To prevent such outcomes, monitoring blood sugar levels every hour is necessary during the initial stages of treatment.

Another common issue is low potassium levels (hypokalemia). Extremely low potassium levels could result in muscle weakness, risky heart rhythms, and heart failure. Besides, anticipating and managing hypokalemia are discussed in detail under the DKA management section. Other possible imbalances like high chloride levels, low magnesium levels, and low sodium levels can also occur.

Cerebral edema, or swelling in the brain, is uncommon in adults compared to children. Risk factors include being a child or a new diabetes patient, having a long duration of symptoms, low levels of carbon dioxide, severe acidosis, and sodium levels, or high glucose levels upon arrival. Also, fast hydration and persisting stomach fluid might make it more likely.

Rhabdomyolysis, a condition causing muscle breakdown which could lead to kidney failure, may occur, although it’s more common with HHS – a serious diabetes complication. Severe hypophosphatemia (low phosphate levels) linked to DKA could further cause rhabdomyolysis.

Acute respiratory failure is another issue often associated with DKA, and could be a result of pneumonia, ARDS (a serious lung condition), or pulmonary edema (fluid accumulation in the lungs). It is important to note that there are two types of fluid accumulation in the lungs linked to DKA: one related to increased pulmonary venous pressure and the other due to increased permeability of lung capillaries.

Lastly, TTP (a rare blood disorder) and myocarditis (inflammation of the heart muscle) are less common complications associated with DKA.

Preventing Adult Diabetic Ketoacidosis

All individuals affected by diabetes should receive thorough information about the disease, including its short-term and long-term effects. They need to learn how and when to monitor their blood sugar levels. Furthermore, they must understand how to properly use their diabetes medications, whether in pill form or insulin injections, know their potential side effects, and realize the importance of consistently taking these medications. Experts like dieticians, nurses, and a variety of home health professionals can play a vital role in helping ensure this information is understood.

Frequently asked questions

Adult Diabetic Ketoacidosis is a dangerous condition that can occur in adults with diabetes. It is marked by high blood sugar levels, acidity in the body, and the presence of ketones in the blood. It can happen in both type-1 and type-2 diabetes patients.

The incidence rate of adult Diabetic Ketoacidosis can range from none to 56 instances per 1000 people each year.

Signs and symptoms of Adult Diabetic Ketoacidosis include: - Eating more than usual (polyphagia) - Excessive urination (polyuria) - Extreme thirst (polydipsia) - Less sweating - Dry mouth - Decreased urine output - Lack of appetite - Nausea - Stomach pain - Vomiting - Weight loss - Fever - Increased heart rate (tachycardia) - Rapid breathing (tachypnea) - Fever or unusually low body temperature if triggered by an infection - Changes in blood pressure, including low blood pressure in serious cases - Unwell appearance - Rapid and deep breathing (Kussmaul breathing) - Fruity smell on the breath due to the presence of acetone - Signs of dehydration, such as slow blood refill in the capillaries, poor skin elasticity, and dry mucous membranes - Abdominal tenderness - Altered mental status in severe cases, requiring immediate attention.

Adult Diabetic Ketoacidosis can be caused by factors such as stressful health events (injury, surgery, infection), not taking diabetes medications properly, certain medications (corticosteroids, thiazides, sympathomimetic agents, pentamidine, antipsychotic drugs), SGLT2 inhibitors, and not adhering to insulin treatments.

The doctor needs to rule out the following conditions when diagnosing Adult Diabetic Ketoacidosis: - Hyperosmolar hyperglycemic nonketotic syndrome - Starvation ketosis - Myocardial infarction - Pancreatitis - Alcoholic ketoacidosis - Lactic acidosis - Sepsis - Exposure to toxins like ethylene glycol, methanol, paraldehyde, salicylate - Overdose on medication for diabetes - Uremia

The types of tests that are needed for adult diabetic ketoacidosis include: - Blood glucose level measurement (should be higher than 250 mg/dl) - Arterial blood pH measurement (should be less than 7.3) - Serum bicarbonate level measurement (should be less than 15 mEq/l) - Presence of ketones in blood or urine - Anion gap measurement (should be more than 14-15 mEq/l) - Complete blood count (CBC) to check for leukocytosis - Sodium level measurement (may be incorrectly low) - Potassium level measurement (usually high but can decrease quickly with insulin) - Magnesium level measurement (often low and requires replenishment) - Phosphate level measurement (may be high but body may still be lacking) - Cultures of urine, sputum, and blood to check for infections - Chest radiograph to check for pneumonia - Serum lipase measurement to check for pancreatitis - A1C test to show glucose trends over several months - Ketone body ratio measurement (3-beta-hydroxybutyrate to acetoacetate) - Electrocardiogram (ECG) to check for heart-related changes - Imaging tests such as CT scan or MRI to distinguish between DKA and acute pancreatitis, check for lung issues, or detect brain swelling.

Adult diabetic ketoacidosis is typically treated through a combination of restoring and maintaining fluid levels, administering insulin, replacing electrolytes, and providing supportive care. Hydration is crucial to counteract dehydration and remove harmful ketones from the body. Isotonic fluids, such as normal saline, are often used, and the infusion rate is adjusted based on the patient's needs. Intravenous insulin is commonly used and is tapered down as blood sugar levels decrease. Potassium and sometimes magnesium supplementation may be necessary. Maintenance and monitoring of hydration, electrolyte levels, and blood sugar levels are important, as well as managing complications and treating underlying causes.

When treating adult Diabetic Ketoacidosis (DKA), there are several potential side effects and complications that can arise. These include: - Low blood sugar levels (hypoglycemia), occurring in roughly 5-25% of patients, which can lead to seizures, abnormal heart rhythms, and cardiovascular events. - Low potassium levels (hypokalemia), which can result in muscle weakness, risky heart rhythms, and heart failure. - Imbalances in other electrolytes such as high chloride levels, low magnesium levels, and low sodium levels. - Cerebral edema, or swelling in the brain, although this is more common in children compared to adults. Risk factors include being a child or a new diabetes patient, long duration of symptoms, low levels of carbon dioxide, severe acidosis, and sodium levels, or high glucose levels upon arrival. - Rhabdomyolysis, a condition causing muscle breakdown which could lead to kidney failure. This is more common with HHS, another serious diabetes complication, but can also occur with DKA. - Acute respiratory failure, which can be a result of pneumonia, ARDS (a serious lung condition), or pulmonary edema (fluid accumulation in the lungs). There are two types of fluid accumulation in the lungs linked to DKA: one related to increased pulmonary venous pressure and the other due to increased permeability of lung capillaries. - Less common complications associated with DKA include TTP (a rare blood disorder) and myocarditis (inflammation of the heart muscle).

The prognosis for adult diabetic ketoacidosis (DKA) can vary depending on several factors. Mortality rates tend to be higher in the elderly and in people with serious concurrent illnesses. However, mortality rates due to hyperglycemic crisis among adults with diabetes have been falling in the United States. With increased vigilance for diabetes, early aggressive treatment of high blood sugar, and improved access to healthcare, both the morbidity and mortality from DKA in older people can be significantly reduced.

An endocrinologist or a primary care physician can be consulted for Adult Diabetic Ketoacidosis.