Diabetes & The Body

Diabetic keto acidosis

Miss Swaroopa, aged 18 years and diabetic of 5 years, suddenly went into sever dehydration and coma. She had a history of bad cold for the past week and her physician held this infection responsible for her present state. Her family was skeptic since it was only a simple cold.

Diabetic keto-acidosis (DKA), as her present predicament is called, is the acidification of the blood because of certain byproducts of energy producing mechanism, called as the ketone bodies. The normal ketone body production in the body is so negligible that they are safely eliminated in urine. But when they are produced in large quantities, they overwhelm our waste disposable mechanism, the kidneys and start accumulating in the blood resulting in DKA

Risk profile

The people at risk of DKA are:

• Type 1 diabetics more than type 2, but both are at risk
• Persons with uncontrolled sugars
• Persons with increased body energy demands like in pregnancy, after heart attack, after surgery and the most important of all the risk factors the presence of infection , any where in the body.

Mechanism of action

• The basic mechanism is that the excess of the ketone bodies produced along with excess of sugars leads to excessive loss of water from the body. This results in severe dehydration.
• The direct effect of the ketone bodies on the brain causing confusion etc
• The effects of acidity caused by the ketones on the basic salts or electrolytes of the body.

Symptoms

• The presence of fever
• Excessive thirst
• Excess hunger
• Confusion
• Rapid and deep breathing etc

Signs

These are Laboratory findings

• Blood sugars more than 250
• Sugars in the urine
• Ketone bodies in the urine
• Acidosis of the blood (ph of the blood more than the normal 7.45 upper limit)
• Presence of infection features in the routine blood tests like the increase in number of white blood cells of the body.

Clinical

• Loss of skin turgor
• Low blood pressure
• High pulse rate
• Sunken eyes
• Less urine production
• Rapid deep breathing
• Fruity odor of the breath because of the ketones.
• Some times the presence of fever, which though is a rare event even in the presence of infection

Management

First step is to shift the patient to a hospital as soon as diagnosed as DKA since it is a medical emergency, which can be fatal. Then the next step is to confirm the diagnosis of DKA by 3 simple tests that are blood sugar test, urinary ketrone test and the arterial blood gas test.

• Blood sugar test this is done in a minute by the glucometers available now a days throughout the world . This has to be repeated every hour till the sugar levels are brought down to about 250 or so
• Urine testing this is done, using the re agent strips giving results in a single minute . The presence of urinary ketones is the usual sine qua non of DKA.
• Artrial blood gasses ABG as it is also called measures the acidity of the blood along with many other things and result is available within minutes.
• Additional tests like x-ray, etc are done to find out and confirm the presence, source, site and causative agent of the infection etc

Treatment

The main mode of treatment is to increase the glucose utilization there by stopping further production of ketones. This is done by continuous insulin infusion initially and then periodic injections , all under proper physician guidance and periodic sugar monitoring.

The next important part is to increase the excretion of the ketones and to improve the dehydration by rapid administration of appropriate fluids intravenously.

Next strategy is to neutralize the acidity of the bloods by giving some alkaline injections like sodium bicarbonate etc that would in turn assist in clearing off of confusion, rapid breathing etc

The next modality is to treat the precipitating cause like antibiotics For infection, treating heart attack if any etc. And finally other supportive measures till the patients recover like taking care of the nutrition etc.

Prevention

The adage prevention is better than cure applies very appropriately here since e simple steps like the following can help prevent the onset of this emergency

• Periodic blood sugar check up and adjusting the dosages of the drugs for diabetes
• Checking the urinary ketones if in any stressful condition
• Prompt physician referral and treatment of any infection
• Emergent admission and treatment in hospital as soon as diagnosed as DKA.