Diabetic ketoacidosis is a decompensated form of diabetes mellitus that occurs with an increase in the level of glucose and ketone bodies in the blood. It is characterized by thirst, increased urination, dry skin, acetone breath, abdominal pain. On the part of the central nervous system, there is the appearance of headaches, lethargy, irritability, drowsiness, lethargy. Ketoacidosis is diagnosed according to biochemical blood and urine tests (glucose, electrolytes, ketone bodies, ABB). The basis of treatment is insulin therapy, rehydration measures and correction of pathological changes in electrolyte metabolism.
Meaning
Diabetic ketoacidosis (DKA) is an acute breakdown of the mechanisms of regulation of metabolism in patients with diabetes mellitus, accompanied by hyperglycemia and ketonemia. It is one of the most common complications of diabetes mellitus (DM) in endocrinology. It is registered in about 5-8 cases per 1000 patients with type 1 diabetes per year, is directly related to the quality of medical care for patients with diabetes mellitus. Mortality from ketoacidotic coma ranges from 0.5-5% and depends on the current hospitalization of the patient in the hospital. Basically, this complication occurs in people under 30 years of age.
Causes
The cause of acute decompensation is absolute (in type 1 diabetes mellitus) or pronounced relative (in type 2 diabetes mellitus) insulin insufficiency. Ketoacidosis may be one of the variants of the manifestation of type 1 diabetes in patients who do not know about their diagnosis and do not receive therapy. If the patient is already receiving treatment for diabetes, the reasons for the development of ketoacidosis may be:
- Inadequate therapy. It includes cases of incorrect selection of the optimal dosage of insulin, untimely transfer of the patient from tableted hypoglycemic drugs to hormone injections, malfunction of the insulin pump or syringe pen.
- Non-compliance with the doctor’s recommendations. Diabetic ketoacidosis can occur if the patient incorrectly adjusts the dosage of insulin depending on the level of glycemia. Pathology develops when using expired drugs that have lost their medicinal properties, independently reducing the dosage, unauthorized replacement of injections with tablets or complete rejection of hypoglycemic therapy.
- A sharp increase in the need for insulin. It usually accompanies conditions such as pregnancy, stress (especially in adolescents), injuries, infectious and inflammatory diseases, heart attacks and strokes, concomitant pathologies of endocrine origin (acromegaly, Cushing’s syndrome, etc.), surgical interventions. The cause of ketoacidosis may be the use of certain medications, due to which the level of glucose in the blood increases (for example, glucocorticosteroids).
In a quarter of cases, it is not possible to reliably determine the cause. The development of the complication cannot be associated with any of the provoking factors.
Pathogenesis
The main role in the pathogenesis of diabetic ketoacidosis is assigned to the lack of insulin. Without it, glucose cannot be utilized, resulting in a situation called “hunger among abundance”. That is, there is enough glucose in the body, but its use is impossible. In parallel, hormones such as adrenaline, cortisol, STH, glucagon, ACTH are released into the blood, which only enhance gluconeogenesis, further increasing the concentration of carbohydrates in the blood. As soon as the renal threshold is exceeded, glucose enters the urine and begins to be excreted from the body, and with it a significant part of the fluid and electrolytes is excreted.
Due to blood thickening, tissue hypoxia develops. It provokes the activation of glycolysis via the anaerobic pathway, which increases the content of lactate in the blood. Due to the impossibility of its utilization, lactatacidosis is formed. Contrinsular hormones trigger the lipolysis process. The liver receives a large amount of fatty acids, acting as an alternative energy source. Ketone bodies are formed from them. With the dissociation of ketone bodies, metabolic acidosis develops.
Classification
According to the severity of the course, diabetic ketoacidosis is divided into three degrees. The evaluation criteria are laboratory parameters and the presence or absence of consciousness in the patient.
- Easy degree. Plasma glucose is 13-15 mmol/l, arterial blood pH ranges from 7.25 to 7.3. Serum bicarbonate is from 15 to 18 mEq/l. The presence of ketone bodies in the analysis of urine and blood serum +. The anionic difference is above 10. There are no violations of consciousness.
- The average degree. Plasma glucose in the range of 16-19 mmol/l. The range of arterial blood acidity is from 7.0 to 7.24. Serum bicarbonate is 10-15 meq/l. Ketone bodies in urine, blood serum ++. There are no disturbances of consciousness or drowsiness is noted. The anionic difference is more than 12.
- Severe degree. Plasma glucose is above 20 mmol/l. The arterial blood acidity index is less than 7.0. Serum bicarbonate is less than 10 mEq/l. Ketone bodies in urine and blood serum +++. The anionic difference exceeds 14. There are disturbances of consciousness in the form of sopor or coma.
Diabetic ketoacidosis symptoms
DKA is not characterized by sudden development. Symptoms of pathology usually form within a few days, in exceptional cases, their development may take up to 24 hours. Ketoacidosis in diabetes goes through the stages of precoma, beginning ketoacidotic coma and complete ketoacidotic coma.
The first complaints of the patient, indicating the state of precoma, are unquenchable thirst, frequent urination. The patient is concerned about the dryness of the skin, their peeling, an unpleasant feeling of tightness of the skin. When the mucous membranes dry out, complaints of burning and itching in the nose appear. If ketoacidosis is formed for a long time, severe weight loss is possible. Weakness, fatigue, loss of working capacity and appetite are characteristic complaints for patients who are in a state of precoma.
The beginning ketoacidotic coma is accompanied by nausea and vomiting attacks, which do not bring relief. There may be abdominal pain (pseudoperitonitis). Headache, irritability, drowsiness, lethargy indicate involvement in the pathological process of the central nervous system. Examination of the patient allows to establish the presence of an acetone odor from the oral cavity and a specific respiratory rhythm (Kussmaul’s breathing). Tachycardia and arterial hypotension are noted. Complete ketoacidotic coma is accompanied by loss of consciousness, decreased or complete absence of reflexes, pronounced dehydration.
Complications
Diabetic ketoacidosis can lead to the development of pulmonary edema (mainly due to incorrectly selected infusion therapy). Arterial thrombosis of various localization is possible as a result of excessive fluid loss and increased blood viscosity. In rare cases, brain edema develops (mainly occurs in children, often ends fatally). Due to a decrease in the volume of circulating blood, shock reactions are formed (acidosis accompanying myocardial infarction contributes to their development). With prolonged stay in a coma, it is impossible to exclude the addition of a secondary infection, most often in the form of pneumonia.
Diagnostics
Diagnosis of ketoacidosis in DM can be difficult. Patients with symptoms of peritonitis, nausea and vomiting often end up not in endocrinological, but in surgical departments. To avoid non-core hospitalization of the patient, the following diagnostic measures are carried out:
- Consultation with an endocrinologist or diabetologist. At the reception, the specialist assesses the general condition of the patient, if consciousness is preserved, clarifies complaints. The initial examination provides information about dehydration of the skin and visible mucous membranes, a decrease in soft tissue turgor, and the presence of abdominal syndrome. The examination reveals hypotension, signs of impaired consciousness (drowsiness, lethargy, complaints of headaches), the smell of acetone, Kussmaul’s breathing.
- Laboratory test. With ketoacidosis, the concentration of glucose in the blood plasma is higher than 13 mmol /l. The presence of ketone bodies and glucosuria in the patient’s urine is determined (diagnosis is carried out using special test strips). A blood test reveals a decrease in the acid index (less than 7.25), hyponatremia (less than 135 mmol / L) and hypokalemia (less than 3.5 mmol /L), hypercholesterolemia (more than 5.2 mmol / L), increased plasma osmolarity (more than 300 mosm / kg), increased anionic difference.
ECG is important to exclude myocardial infarction, which can lead to electrolyte disorders. Chest x-ray is necessary to exclude secondary infectious damage to the respiratory tract. Differential diagnosis of diabetic ketoacidotic coma is carried out with lactic acid coma, hypoglycemic coma, uremia. Differential diagnosis with hyperosmolar coma is rarely of clinical significance, since the principles of treatment of patients are similar. If it is impossible to quickly determine the cause of loss of consciousness in patients with diabetes mellitus, it is recommended to administer glucose to stop hypoglycemia, which is much more common. The rapid improvement or deterioration of a person’s condition against the background of glucose administration makes it possible to determine the cause of loss of consciousness.
Diabetic ketoacidosis treatment
Treatment of the ketoacidotic condition is carried out only in a hospital setting, with the development of coma – in an intensive care unit. Bed rest is recommended. Therapy consists of the following components:
- Insulin therapy. It is mandatory to adjust the dose of the hormone or to select the optimal dosage for initially diagnosed diabetes mellitus. Treatment should be accompanied by constant monitoring of the level of glycemia and ketonemia.
- Infusion therapy. It is carried out in three main directions: rehydration, correction of ABB and electrolyte disorders. Intravenous administration of sodium chloride, potassium preparations, sodium bicarbonate is used. An early start is recommended. The amount of the injected solution is calculated taking into account the age and general condition of the patient.
- Treatment of concomitant pathologies. Concomitant heart attack, stroke, and infectious diseases can aggravate the condition of a patient with DKA. For the treatment of infectious complications, antibiotic therapy is indicated, if vascular catastrophes are suspected, thrombolytic therapy is indicated.
- Monitoring of vital signs. Constant electrocardiography, pulse oximetry, assessment of glucose and ketone bodies are carried out. Initially, monitoring is carried out every 30-60 minutes, and after the patient’s condition improves every 2-4 hours during the following days.
Today, developments are underway aimed at reducing the likelihood of developing DKA in patients with diabetes mellitus (insulin preparations in tablet forms are being developed, methods of drug delivery to the body are being improved, methods are being searched for that would allow restoring their own hormone production).
Prognosis and prevention
With timely and effective therapy in a hospital, ketoacidosis can be stopped, the prognosis is favorable. With a delay in the provision of medical care, pathology quickly turns into a coma. The mortality rate is 5%, and in patients over the age of 60 – up to 20%.
The basis for the prevention of ketoacidosis is the training of patients suffering from diabetes mellitus. Patients should be familiar with the symptoms of the complication, informed about the need for proper use of insulin and devices for its administration, trained in the basics of controlling blood glucose levels. A person should be as aware of his disease as possible. It is recommended to lead a healthy lifestyle and follow a diet selected by an endocrinologist. If symptoms inherent in diabetic ketoacidosis develop, it is necessary to consult a doctor to avoid negative consequences.
