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Diabetic Ketoacidosis (DKA) or High Blood Sugar

Published:
27-March-2005

By H. Peter Chase, MD
Barbara Davis Center for Childhood Diabetes
Department of Pediatrics

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One emergency in diabetes is high blood sugar (hyperglycemia), the appearance of moderate or large ketones in the urine, which can develop into acidosis. Large ketones are usually present in the urine for at least four hours before the total body's acidity is increased (acidosis). Acidosis is very dangerous and people can go into a coma or die from it. It is the cause for 85% of hospitalizations of children with known diabetes. The good news is that it is 98% preventable if people follow instructions and always remember to take their insulin.

Acidosis is due to there not being enough insulin available to meet the body's needs. The three main causes are:

  • Illness
  • Forgetting to take an insulin shot
  • Not enough insulin

With an illness, the body may need extra energy. This cannot be made unless extra insulin is available to make the extra energy from sugar. If a shot is forgotten, insulin is not available to the body. A lack of insulin could happen in a person coming out of the "honeymoon" period who has not had insulin doses adequately increased.

The blood sugar is usually high with acidosis because insulin is not turning off the body's machinery for making sugar and for making ketones. This is because not enough insulin is available. Also, the stress hormones are high with illness and they act to increase blood sugar and ketone production. The high blood sugar can cause sugar to pass into the urine and the person must go to the bathroom a lot (frequent urination). The body may lose too much water and become too dry (dehydration). The tongue may feel dry and furry. Drinking lots of fluids may help this. The main treatment however, is taking extra insulin to shut off the body's machinery for making sugar and ketones.

It is not high blood sugar that causes acidosis. In fact eating sugar does not cause acidosis. Ketones come from the breakdown of body fat. One of the roles of insulin is to shut-off fat breakdown. Because enough insulin is not available and because stress hormones are high, fat begins to break down. The side-product of fat breakdown is keytone production. Keytones are initially passed into the urine. They may start with trace or small levels and gradually build up to moderate and then, to large levels. Once they reach the large level, they may start to build up in the body tissues. They are easier to reverse if treated at the moderate level before building up. The longer someone has large urine ketones, the more likely they are to build up in the body and result in acidosis (DKA). Thus, early detection and reversal by giving extra insulin is critical. There are several reasons why fat is broken down:

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  • Not enough insulin is available to help the cells burn the needed sugar.
  • The body needs more energy (e.g., for illness) and the fat is broken down to provide this energy.
  • The stress hormones, steroids, adrenaline (epinephrine) and glucagon have been released, causing fat breakdown.
  • Sugar is not available due to vomiting or not eating: thus, fat is broken down for energy. Anytime fat is broken down for energy, ketones are formed.

Symptoms Of Acidosis

In any of these cases fat is broken down. The ketones are made from fat. Acidosis usually comes on slowly, over several hours, and has the following symptoms:

  • Upset stomach and/or stomach pain
  • Vomiting
  • Sweet (fruity) odor to the breath
  • Thirst and frequent urination (if the blood sugar is high)
  • Drowsiness
  • Deep breathing (indicates need to go to the emergency room)
  • If not treated, coma (loss of consciousness)

Prevention Of Ketoacidosis

  • Remember to check urine ketones with any illness (even an upset stomach or vomiting one time) or anytime the blood sugar level is above 240 mg/dl
  • Call the diabetes care provider immediately (night or day) if moderate or large keytones are found
  • Take extra insulin (after checking the blood sugar and urine ketones) every two hours for Humalog or every three hours for regular insulin until the urine keytones are small or less
  • If the blood sugar falls below 150 mg/dl and urine ketones are still moderate or large, drink juice (preferably orange as it replaces potassium). Pedialyte or sugared pop to keep the blood sugar up so that more insulin can be given to turn off the ketone production
  • Drink lots of fluids to help wash out the ketones

The prevention of acidosis is based on being able to detect changes early, when ketones are present in the urine, but before the ketones build up in the body.

By H. Peter Chase, MD
Barbara Davis Center for Childhood Diabetes
2002