Diabetes Ketoacidosis: Why It Happens & What To Do

I remember a young man, just starting college, brought in by his roommate. He was pale, breathing so fast it looked exhausting, and there was this… sweet, almost nail-polish-remover smell on his breath. His roommate said he’d been incredibly thirsty and tired for days. My mind immediately jumped to one thing: Diabetes-Related Ketoacidosis, or DKA as we often call it. It’s a serious situation, a real medical emergency, and something anyone with diabetes, or even someone who doesn’t yet know they have it, needs to understand.

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What Exactly is DKA, and Who’s at Risk?

So, let’s talk about this. It can sound pretty scary, and it is serious, but understanding it is the first step.

Understanding Diabetes-Related Ketoacidosis (DKA)

What is DKA? Imagine your body is a car. Normally, insulin – that’s a crucial hormone – acts like the key that lets sugar (glucose) from your food get into your cells to be used for fuel. Now, if you don’t have enough insulin, or it’s not working right, that sugar stays stuck in your blood. Your body, desperate for energy, starts burning fat instead. It’s like trying to run your car on a different, less efficient fuel.

This fat-burning process creates byproducts called ketones. A few ketones? Not usually a problem. But when they build up, they make your blood too acidic. Think of it like your body’s chemistry going way off balance. Plus, all that extra sugar in your blood makes you pee a lot, leading to dehydration. This combination – acidic blood and dehydration – is what makes DKA so dangerous. It needs attention, fast.

Who Typically Faces DKA?

This serious condition, Diabetes-Related Ketoacidosis, can pop up in a few scenarios:

Newly Diagnosed Type 1 Diabetes: Often, DKA is the dramatic way someone finds out they have Type 1 diabetes. This can happen in childhood, teen years, or even adulthood. You don’t need a family history for Type 1 to develop. It’s surprising, but for about 20% to 40% of folks, DKA is their first major clue.
Existing Type 1 Diabetes: If you have Type 1 and you’re not getting enough insulin (whether injected or from a pump), DKA is a risk.
Type 2 Diabetes: It’s less common, but some people with Type 2 diabetes, particularly those with something called ketosis-prone diabetes, can also develop DKA. More often, though, folks with Type 2 diabetes might face a different issue called hyperosmolar hyperglycemic state (HHS), which is another serious condition we watch out for.

Spotting the Warning Signs of DKA

How would you know if DKA is knocking on the door? It can sneak up, sometimes within 24 hours. If you’re vomiting, it can happen even faster.

The early whispers might be:

You’re running to the bathroom way more than usual (frequent urination).
You’re incredibly thirsty, like you can’t get enough to drink (we call this polydipsia).
You might feel intensely hungry (polyphagia).
Signs of dehydration creep in: your mouth feels dry, you might have a headache, or your skin looks flushed.
If you test at home, you’d see high amounts of ketones in your urine or blood.
Your blood sugar is likely high, often over 250 mg/dL. Though, sometimes – and this is a bit tricky – DKA can happen with lower blood sugars too. We call that euglycemic DKA.

If things get more serious, DKA shouts louder:

Nausea and maybe even vomiting.
Achy abdominal pain.
Breathing that’s rapid and deep – we call this Kussmaul breathing. It’s your body’s way of trying to blow off the extra acid.
A distinct fruity-smelling breath. Some folks say it’s like pear drops or nail polish remover. Weird, right?
Feeling wiped out, very tired, or weak.
Feeling disoriented or confused.
Decreased alertness, or in severe cases, loss of consciousness.

If you or someone you know has these symptoms, especially the more severe ones, it’s not a ‘wait and see’ situation. It’s time to call your doctor right away or head to the nearest emergency room.

What Triggers an Episode of Diabetes-Related Ketoacidosis?

The main culprit behind Diabetes-Related Ketoacidosis is simply not having enough insulin doing its job. But why would that happen?

A New Diagnosis of Type 1 Diabetes: Like we talked about, if your body has stopped making insulin and you don’t know it yet.
Missing Insulin Doses: Life happens! Forgetting or skipping insulin, especially with meals, can be a big trigger if you’re insulin-dependent.
Insulin Pump Problems: If you use an insulin pump, things like a kinked tube (the soft tube under your skin is called a cannula), a disconnected site, or just running out of insulin in the pump can stop the flow.
Insulin Gone Bad: Insulin is sensitive. If it gets too hot or too cold, or if it’s past its expiry date, it might not work properly. Always check how to store your specific type.

Sometimes, your body just needs more insulin than usual. Certain situations crank up your body’s stress hormones (like cortisol and adrenaline), making it harder for insulin to work (this is insulin resistance). These include:

Illness: Especially with vomiting, as dehydration can make DKA develop faster.
Infection: Common ones are pneumonia, urinary tract infections (UTIs), or skin infections.
Severe Physical Injury or Emotional Trauma.
Surgery.
A heart attack or stroke.
Pregnancy.

Other triggers, though less common, can include:

Pancreatitis: Inflammation of the pancreas can sometimes mess with insulin production.
Alcohol use disorder or substance use disorder: Alcohol and some substances, like cocaine, can make your body produce hormones that make it difficult to use insulin properly. Plus, you’re more likely to miss doses of insulin if you use substances.
Certain Medications: Some drugs, like specific antipsychotic medications, diuretics (water pills), a class of diabetes meds called SGLT2 inhibitors, and corticosteroids (often used for inflammation), can unfortunately be a factor.

How We Figure Out if It’s DKA: Diagnosis and Tests

When we suspect DKA, we need to confirm it. It’s a bit like putting puzzle pieces together. Usually, we’re looking for a combination of four things:

Your blood glucose (sugar) level is above 250 mg/dL. (Though, as I mentioned, it’s possible to have DKA if your blood sugar is lower – that euglycemic DKA can be a curveball.)
Your blood pH is less than 7.3 (this means it’s acidosis).
You have ketones in your urine and/or blood.
Your blood bicarbonate level is less than 18 mEq/L. Bicarbonate is a substance that helps keep your blood’s pH balanced.

In the hospital, we’ll likely run a few tests to get the full picture:

A blood glucose test, naturally.
Ketone testing, either with a urine sample or a blood test.
An arterial blood gas (ABG). This is a blood test, usually from an artery in your wrist. It’s very good at telling us the precise pH of your blood and other important gas levels.
A basic metabolic panel (BMP). This is a common blood test that checks your kidney function, electrolytes (minerals like potassium and sodium that need to be in balance), and blood sugar.
We’ll also check your blood pressure and sometimes an osmolality blood test, which looks at the concentration of different particles in your blood.

If you’re at home and worried, and you have diabetes, you can do a few checks yourself before calling us (though please, always call if you’re concerned!):

Urine ketone test: These are strips you can buy at the pharmacy. You dip them in your urine, and they change color to show ketone levels. Just follow the instructions on the box.
Blood ketone test: Some at-home blood glucose meters can check blood ketones as well as blood sugar levels with a special strip.
Blood sugar checks: Knowing your number is key. If it’s high (over 250 mg/dL) and you have symptoms, that’s a definite flag.

Getting Back on Track: DKA Treatment

Okay, so if it is Diabetes-Related Ketoacidosis, what do we do? The good news is, with prompt treatment, people usually start feeling much better within about 24 hours. Sometimes it takes a bit longer, but we get there.

If you catch it super early and you already have a diabetes plan, sometimes your doctor might guide you on managing it at home. But, and this is a big but, you must call your doctor first. They’ll decide if home treatment is safe for you. If you don’t have diagnosed diabetes, or if your symptoms are serious, hospital treatment is essential. No question.

Here’s what usually happens in the hospital:

IV fluids: We’ll get an intravenous line (an IV) going to give you fluids directly. This helps with the dehydration, helps flush out those ketones through your urine, and helps get your electrolytes back in balance. This is really, really important.
Insulin: You’ll get insulin, often through the IV at first, or sometimes as an injection under the skin (a subcutaneous shot). This is key to stopping your body from making more ketones and allowing it to use sugar for energy again.
Other treatments: Depending on the severity of DKA, and if there was an underlying trigger like an infection, you might need other things, like antibiotics if a bacterial infection is found.

If your doctor says you can manage early DKA at home, here’s the general idea (but always, always follow their specific instructions – this isn’t a one-size-fits-all):

Follow their insulin plan: They’ll tell you exactly how much extra insulin to take and when.
Check your blood sugar often: Maybe every hour, to make sure it’s coming down safely (not too fast!).
Keep checking ketones: You want to see those ketone levels dropping, not rising.
Drink fluids to prevent dehydration: Water, broth, sugar-free drinks are your friends. This is super important if you’ve been vomiting.
Try to eat normally: It’s important to eat as you normally do, especially if you’re sick. If you take insulin, be sure to take the appropriate amount with your meal as directed by your provider.
Don’t exercise: Physical activity can actually increase your blood sugar and increase ketones in your body when you’re in this state. Your provider will let you know when you can safely start exercising again.

It’s a serious condition, DKA. If it’s not treated quickly, it can lead to some scary complications like very low potassium levels (hypokalemia), swelling in the brain (cerebral edema – this is something we worry about particularly in younger people), fluid inside of your lungs (pulmonary edema), cardiac arrest, damage to your kidneys and other organs, coma, and in rare cases, it can be fatal. That’s why getting help fast is so crucial. The survival rate is actually very high, over 95%, when it’s treated properly and promptly.

Preventing DKA: Your Game Plan

Now, the best treatment is always prevention, right? If you have diabetes, here are some things that can really help lower your risk of Diabetes-Related Ketoacidosis:

Checking your blood sugar often: Knowing your numbers with a glucose meter and/or using a CGM is crucial. Try to at least check your blood sugar before and after meals and before you go to sleep. It’s important to treat high blood sugar as soon as possible.
Taking your insulin and/or medication regularly: Follow your healthcare provider’s instructions. Missed doses can definitely lead to DKA.
Checking for ketones: If you’re experiencing sustained high blood sugar, or if you’re sick, check for ketones using a pee or blood test to be sure you’re not close to developing DKA.
Checking your insulin pump: If you use an insulin pump and are experiencing high blood sugar, be sure to check your pump for issues like a kinked cannula or a disconnected site/tubing.
Having a sick day plan: Talk with your provider about how to manage diabetes when you’re sick. Illness can trigger DKA, so it’s important to know what to do before it happens.
Seeing your diabetes provider regularly: It’s important to see your diabetes provider regularly to be sure that your diabetes management plan is working.
Staying educated: Don’t be afraid to ask your healthcare team about DKA. The more you know, the more likely you’ll be able to prevent it or catch it early.

And listen, even with the best efforts, sometimes DKA can happen. Life throws curveballs. If it happens, try not to be hard on yourself. The most important thing is to recognize the signs and get help as soon as possible.

DKA vs. Ketosis: What’s the Difference?

You might hear the word ‘ketosis’ and ‘ketoacidosis’ and think they’re the same. They sound similar, but they’re very different beasts!

Ketosis happens when you have ketones in your blood and/or pee but not enough to turn your blood acidic. It usually happens if you are eating a low-carbohydrate (keto) diet, aren’t eating for long periods (fasting), or have consumed excessive alcohol. Ketosis itself isn’t harmful.
Diabetes-Related Ketoacidosis (DKA), on the other hand, happens when your blood turns acidic because there are too many ketones in your blood due to a lack of insulin. DKA is life-threatening and requires immediate treatment.

So, ketones themselves aren’t always bad. It’s the why and how many that make all the difference.

Your Take-Home Message on Diabetes-Related Ketoacidosis

This is a lot to take in, I know. So, what are the absolute must-remembers about Diabetes-Related Ketoacidosis (DKA)?

DKA is a serious, potentially life-threatening complication of diabetes. It’s caused by a lack of insulin, which leads to high blood sugar, a buildup of ketones, and acidic blood.
Be alert for key symptoms: extreme thirst, peeing a lot, nausea, vomiting, belly pain, that fruity breath, and fast, deep breathing.
It can be the very first sign that someone has Type 1 diabetes, or it can happen to people already diagnosed if they don’t get enough insulin.
Getting medical help quickly is vital. Treatment usually involves IV fluids and insulin in a hospital setting.
You can help prevent DKA by checking your blood sugar regularly, taking your insulin or medications as prescribed, checking for ketones when your sugar is high or you’re sick, and having a solid sick-day plan.
Remember, DKA is not the same as simple ketosis from dieting or fasting. DKA is a medical emergency.

Dealing with diabetes, and the potential for things like DKA, can feel overwhelming at times. But you’re not alone in this. We’re here to help you understand and manage it. Keep those lines of communication open with your healthcare team, and please, always reach out if you’re worried. You’re doin’ great just by learning more.

Diabetes Ketoacidosis: Why it Happens & What to Do