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Diabetic Ketoacidosis
A Preventable Crisis

by Jan Chait

People who have had diabetic ketoacidosis, or DKA, will tell you it’s worse than any flu they’ve ever had, describing an overwhelming feeling of lethargy, unquenchable thirst, and unrelenting vomiting.

“It’s sort of like having molasses for blood,” says George. “Everything moves so slow, the mouth can feel so dry, and there is a cloud over your head. Just before diagnosis, when I was in high school, I would get out of a class and go to the bathroom to pee for about 10–12 minutes. Then I would head to the water fountain and begin drinking water for minutes at a time, usually until well after the next class had begun.”

George, generally an upbeat person, said that while he has experienced varying degrees of DKA in his 40 years or so of having diabetes, “…at its worst, there is one reprieve from its ill feeling: Unfortunately, that is a coma.”

But DKA can be more than a feeling of extreme discomfort, and it can result in more than a coma.

“It has the potential to kill,” says Richard Hellman, MD, president of the American Association of Clinical Endocrinologists. “DKA is a medical emergency. It’s the biggest medical emergency related to diabetes. It’s also the most likely time for a child with diabetes to die.”

DKA occurs when there is not enough insulin in the body, resulting in high blood glucose; the person is dehydrated; and too many ketones are present in the bloodstream, making it acidic. The initial insulin deficit is most often caused by the onset of diabetes, by an illness or infection, or by not taking insulin when it is needed.

Ketones are your brain’s “second-best fuel,” Hellman says, with glucose being number one. If you don’t have enough glucose in your cells to supply energy to your brain, your body breaks fat down into small pieces so that it can be used as fuel. Ketones are formed during that process. Everybody has ketones in their bloodstream at some point, even people who don’t have diabetes. Your body sometimes uses them for fuel when you restrict your food intake, when you haven’t eaten for a while — even overnight, in very tiny amounts — and when you exercise.

The problem comes when you have diabetes and lack sufficient insulin to move glucose from your bloodstream into your body’s cells. Your body believes it isn’t getting enough food, so it reacts in two ways: It instructs the liver to turn glycogen (stored glucose) into glucose and release it into the bloodstream, and it begins to use fat for energy. The higher your blood glucose rises, the more fat is used — and the more ketones are formed.

“When you run out of insulin, ketone production becomes excessive,” Hellman says. “It takes approximately two hours after you run out of insulin for excessive ketone accumulation to occur.”

Ketones accumulate in your blood and, from there, go into the urine. That causes excessive urination, which is added to the increased urine production from high blood glucose. You then begin to become dehydrated.

At the same time, the increase in ketone production begins to change your body’s chemistry, and it becomes more acidic. The increased acidity changes the delicate mechanisms that regulate your body — changes that can affect your heart and, perhaps, your brain. In addition to urinating more, your body also tries to get rid of the excess acid by exhaling it, so your breathing becomes shallow and rapid and smells like acetone, or fingernail polish remover. Badly needed fluids may not be retained because of vomiting. Because your body isn’t getting the “food” it needs for energy, you have an overwhelming feeling of sleepiness. And you experience abdominal pain. In fact, Dr. Hellman says, DKA is sometimes misdiagnosed as appendicitis.

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Also in this article:
Hyperosmolar Hyperglycemic State
Signs and Symptoms



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