Diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes mellitus. Signs and symptoms may include vomiting, abdominal pain, deep gasping breathing, increased urination, weakness, confusion and occasionally loss of consciousness. A person's breath may develop a specific 'fruity' smell. Onset of symptoms is usually rapid. In some cases, people may not realize they previously had diabetes. Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes mellitus. Signs and symptoms may include vomiting, abdominal pain, deep gasping breathing, increased urination, weakness, confusion and occasionally loss of consciousness. A person's breath may develop a specific 'fruity' smell. Onset of symptoms is usually rapid. In some cases, people may not realize they previously had diabetes. DKA happens most often in those with type 1 diabetes but can also occur in those with other types of diabetes under certain circumstances. Triggers may include infection, not taking insulin correctly, stroke and certain medications such as steroids. DKA results from a shortage of insulin; in response, the body switches to burning fatty acids, which produces acidic ketone bodies. DKA is typically diagnosed when testing finds high blood sugar, low blood pH and ketoacids in either the blood or urine. The primary treatment of DKA is with intravenous fluids and insulin. Depending on the severity, insulin may be given intravenously or by injection under the skin. Usually, potassium is also needed to prevent the development of low blood potassium. Throughout treatment, blood sugar and potassium levels should be regularly checked. Antibiotics may be required in those with an underlying infection. In those with severely low blood pH, sodium bicarbonate may be given; however, its use is of unclear benefit and typically not recommended. Rates of DKA vary around the world. In the United Kingdom, about 4% of people with type 1 diabetes develop DKA each year, while in Malaysia the condition affects about 25% of type-1 diabetics a year. DKA was first described in 1886 and, until the introduction of insulin therapy in the 1920s, it was almost universally fatal. The risk of death with adequate and timely treatment is around 1–4%. The symptoms of an episode of diabetic ketoacidosis usually evolve over a period of about 24 hours. Predominant symptoms are nausea and vomiting, pronounced thirst, excessive urine production and abdominal pain that may be severe. In severe DKA, breathing becomes rapid and of a deep, gasping character, called 'Kussmaul breathing'. The abdomen may be tender to the point that a serious abdominal condition may be suspected, such as acute pancreatitis, appendicitis or gastrointestinal perforation. Vomiting blood that resembles coffee grounds occurs in a minority of people and tends to originate from erosion of the esophagus. In severe DKA, there may be confusion or a marked decrease in alertness, including coma. On physical examination there is usually clinical evidence of dehydration, such as a dry mouth and decreased skin turgor. If the dehydration is profound enough to cause a decrease in the circulating blood volume, a rapid heart rate and low blood pressure may be observed. Often, a 'ketotic' odor is present, which is often described as 'fruity' or like 'pear drops'. The smell is due to the presence of acetone. If Kussmaul respiration is present, this is reflected in an increased respiratory rate. Small children with DKA are relatively prone to brain swelling, also called cerebral edema, which may cause headache, coma, loss of the pupillary light reflex, and can progress to death. It occurs in about 1 out of 100 children with DKA and more rarely occurs in adults. DKA most frequently occurs in those who know they have diabetes, but it may also be the first presentation in someone who had not previously been known to be diabetic. There is often a particular underlying problem that has led to the DKA episode; this may be intercurrent illness (pneumonia, influenza, gastroenteritis, a urinary tract infection), pregnancy, inadequate insulin administration (e.g. defective insulin pen device), myocardial infarction (heart attack), stroke or the use of cocaine. Young people with recurrent episodes of DKA may have an underlying eating disorder, or may be using insufficient insulin for fear that it will cause weight gain. Diabetic ketoacidosis may occur in those previously known to have diabetes mellitus type 2 or in those who on further investigations turn out to have features of type 2 diabetes (e.g. obesity, strong family history); this is more common in African, African-American and Hispanic people. Their condition is then labeled 'ketosis-prone type 2 diabetes'.