AI Summary Overview
What Is Diabetic Ketoacidosis?
When the body is unable to produce enough insulin to use glucose for energy, it starts to break down fat, releasing acids known as ketones. When these ketones accumulate, the blood becomes too acidic, leading to diabetic ketoacidosis.
There are three main body changes characteristic of DKA: high blood sugar (hyperglycaemia), high ketone levels (ketosis), and increased blood acidity (metabolic acidosis).
DKA is most commonly seen in people with Type 1 diabetes, but people with Type 2 diabetes can also develop the condition in specific situations.
Types of Diabetic Ketoacidosis
DKA is classified based on its severity. The classifications and their levels are:
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Mild DKA In mild DKA, the blood pH remains between 7.25 and 7.30, and the bicarbonate level is usually between 15 and 18 mEq/L. At this stage, the patient should be alert and fully aware, with possible minor symptoms like mild nausea and abdominal pain.
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Moderate DKA Blood pH remains between 7.00 and 7.24 in moderate DKA. In moderate DKA, the bicarbonate level in the blood is between 10 and 15 mEq/L. The patient can feel sleepy and also appear slightly confused or less alert due to high blood glucose levels and electrolyte imbalances.
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Severe DKA Severe DKA is a medical emergency and life-threatening. Blood pH falls below 7.00, which indicates a highly acidic nature. The bicarbonate level also dramatically falls below 10 mEq/L. Untreated severe DKA can lead to severe dehydration, altered consciousness, and life-threatening complications.
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Euglycaemic DKA Euglycaemic DKA is a specific type of DKA in which the blood sugar level is within the normal range, but there is high blood acidity and insulin deficiency. Diagnosis often gets delayed as the blood sugar levels appear normal or near-normal, and this delay can eventually prove to be life-threatening if not caught on time. It is more commonly reported in patients taking an SGLT-2 inhibitor for Type 2 diabetes, pregnant women, or people doing prolonged fasting.
How Common Is DKA in India?
As of 2024, India has 89.8 million adults with diabetes, and the number is estimated to nearly double to 156.4 million in 2050, making complications like DKA a major concern.
Young people with newly detected Type 1 diabetes present with DKA at diagnosis in a surprisingly high percentage. In a study, researchers found that 56% of the DKA patients they studied were aged 18 to 44 years. The same study noted that the mortality risk in developing countries like India ranges as high as 30% for critically ill patients presenting with DKA.
Missed or delayed insulin doses, undetected diabetes, and infections are the most common triggers for DKA cited in Indian studies. It is often missed or diagnosed late owing to the lack of awareness of the patients and their caregivers.
What Are the Symptoms of Diabetic Ketoacidosis?
The symptoms of DKA often appear within 24 hours of development. Symptoms based on the stages are as follows:
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Early Symptoms
- Intense thirst and a dry mouth
- Frequent urination
- High blood sugar levels
- Extreme fatigue or lack of energy
- Vomiting (mild)
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Progressive Symptoms
- Nausea and vomiting
- Abdominal cramps or pain
- No appetite
- Headache
- Sweet or fruity-smelling breath (caused by a type of ketone, called acetone)
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Severe Symptoms
- Deep and laboured breathing (Kussmaul breathing)
- Feeling confused or disoriented
- Severe sleepiness or unresponsiveness
- Passing out
What Causes Diabetic Ketoacidosis?
Causes of DKA include:
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Low Insulin: A lack of insulin production is one of the common causes of DKA. Omission of insulin doses or taking the wrong insulin type is a classic reason for DKA and can happen to anyone. However, in people with type 1 diabetes, the risk of low insulin and eventually DKA is higher than in other diabetes types.
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Infections/Illness: Urinary tract infections, chest infections, stomach upsets, and other infections increase the body's need for insulin, which can rapidly lead to the onset of DKA.
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Newly Diagnosed Diabetes: DKA can be one of the symptoms found when the person is initially diagnosed with type 1 diabetes and may have lacked insulin for some time before diagnosis.
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Physical/Emotional Stress: A traumatic experience, operation, or significant emotional event can increase counter-regulatory hormones. These hormones can further increase glucose levels and decrease insulin action.
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Specific Medications: SGLT2 inhibitors have occasionally been associated with precipitating EDKA in people with Type 2 diabetes, even with almost normal blood glucose.
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Alcohol or Drug Use: Excessive alcohol intake will alter glucose and ketone metabolism and precipitate DKA.
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Malfunction of Insulin Pump: A kinked catheter on an insulin pump may prevent insulin administration without warning.
What Are the Complications of Diabetic Ketoacidosis?
Some of the complications associated with diabetic ketoacidosis include:
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Hypokalaemia (Low Blood Potassium): Insulin treatment in DKA forces potassium out of the blood and into the cells. If not managed carefully, the blood potassium levels can fall and may lead to serious heart complications.
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Cerebral Oedema (Brain Swelling): This is a rare but potentially life-threatening complication of treatment for DKA. It occurs most commonly in children undergoing treatment. A rapid change in fluid and electrolyte balance may lead to brain swelling.
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Acute Kidney Injury: Poor fluid intake associated with DKA leads to a reduced flow of blood to the kidneys. This may lead to both temporary and potentially permanent damage to the kidneys.
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Respiratory Failure: In severe DKA, the body tries to correct the acid buildup by breathing faster and deeper than normal. Severe metabolic acidosis can place a significant burden on the breathing muscles and, in rare cases, lead to respiratory failure.
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Heart Rhythm Problems: Electrolyte imbalances, especially those of potassium and magnesium, can affect electrical conduction within the heart.
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Aspiration Pneumonia: If a patient is unconscious, they might inhale their stomach contents into the lungs, which can lead to pneumonia or lung damage.
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Repeated DKA episodes: If a patient's insulin regimen is not well adhered to, it may lead to recurring DKA episodes with the risk of later long-term complications.
When Should I See My Healthcare Provider?
Contact your healthcare provider immediately if you notice:
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A blood sugar reading higher than 300 mg/dL that doesn't come down with an insulin dose.
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Moderate or high levels of ketones in your urine or blood.
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You can't keep fluids or food down because you're vomiting.
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Your breathing speeds up and becomes very deep or laboured.
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Your breath smells fruity or like acetone (nail polish remover).
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You have difficulty thinking or staying awake.
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An unconscious person does not come back to their senses after repeated attempts.
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The symptoms of DKA have appeared in a child you know doesn't have diabetes yet.
How is Diabetic Ketoacidosis Diagnosed?
The diagnosis of DKA usually entails a combination of blood and urine tests, which include:
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Blood Glucose Test A blood glucose level of above 250 mg/dL is generally found with DKA, although blood glucose is sometimes within the normal range in euglycaemic DKA.
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Blood Ketone Test The current widely accepted method for detecting DKA is a serum beta-hydroxybutyrate level of above 3.0mmol/L through a blood ketone test. This technique is also the most accurate method for ketone measurement.
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Arterial Blood Gas (ABG) Test This test measures the blood pH and bicarbonate levels; a low pH below 7.30 with a low bicarbonate is a marker of metabolic acidosis and is required for the classification of DKA.
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Urine Ketone Test The dipstick test can be performed on a urine sample to determine the presence of ketones. The test can be used for rapid screening of the condition, although blood samples should also be taken for classification and confirmation of diagnosis.
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Serum Electrolytes This test measures blood sodium, potassium, and chloride levels, which can be used to determine the anion gap and guide fluid and electrolyte replacement.
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Complete Blood Count (CBC) and Infection Markers Blood counts are assessed to look for infection, as the infection may be the cause of the DKA. An increased white blood cell count and C-reactive protein can be due to an infection.
Diagnostic Overview Table
| Test Name | Purpose | What the Doctor Checks |
| Blood Glucose Test | Measures blood sugar levels. | High blood glucose levels. |
| Blood Ketone Test | Confirms ketone buildup. | Blood ketone (beta-hydroxybutyrate) levels. |
| Arterial Blood Gas (ABG) Test | Checks blood acidity. | Blood pH and bicarbonate levels. |
| Urine Ketone Test | Screens for ketones quickly. | Presence of ketones in urine. |
| Serum Electrolytes Test | Assesses electrolyte balance. | Sodium, potassium, chloride, and anion gap. |
| Complete Blood Count (CBC) and Infection Markers | Looks for infection. | White blood cell count, CRP, and other infection markers. |
How is Diabetic Ketoacidosis Managed?
Common management and treatment practices for diabetic ketoacidosis are:
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Fluid Replacement Rehydration is the first course of treatment in DKA. Doctors often administer fluid (often normal saline) intravenously (IV) to re-expand blood volume and improve kidney function.
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Insulin Therapy Insulin is delivered via IV infusion to reduce blood sugar and stop ketone production gradually. Fast blood sugar correction should be avoided due to the risk of cerebral oedema. If the blood sugar level falls to 200-250 mg/dL, the doctor may change the type and rate of insulin.
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Electrolyte Correction Potassium, magnesium, and phosphate levels need careful observation and supplementing, as they can drop rapidly with insulin administration.
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Trigger Treatment The trigger, for example, an infection or another illness, needs to be treated at the same time as DKA. Antibiotics may be administered if there is an existing infection.
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Continued Monitoring Medical professionals monitor blood glucose, blood gases, and electrolytes on an hourly to two-hourly basis. They also observe urine output. Most patients show marked improvement within 12 to 24 hours, but the time required for recovery depends on the severity of the condition and underlying causes.
Diabetic Ketoacidosis During Pregnancy
DKA can also happen during pregnancy and can occur even when the blood sugar level is lower than for a non-pregnant woman. Pregnant women with Type 1 diabetes and those who have developed gestational diabetes are also at an increased risk of developing DKA due to the effects of hormonal changes on insulin resistance.
During pregnancy, DKA can be life-threatening for the mother and baby. Potential dangers in pregnancy include premature labour and foetal distress. Pregnant women with established diabetes need to report symptoms to a medical professional immediately to prevent complications.
What is the Prognosis of DKA?
Prompt and effective management often leads to complete resolution of a DKA episode. The mortality associated with a DKA episode, when managed in a well-equipped hospital environment and with rapid presentation, is quite low.
However, according to the previously mentioned study, mortality can be as high as 30% among severe DKA patients due to a lack of awareness and limited access to ICU facilities, as well as other infections in non-metro cities in India.
It is recommended that patients recovering from a DKA episode stay in touch with their doctor to avoid future DKA episodes. Continuing the prescribed insulin regimen and routine monitoring can reduce the chances of recurring DKA episodes.
How Can Diabetic Ketoacidosis Be Prevented?
The following measures can reduce the chances of DKA episodes:
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Do not miss insulin doses at any time, particularly when sick or not eating.
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Check your blood sugar frequently when you are sick or stressed.
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Check your urine or blood ketone levels when your blood sugar is over 250 mg/dL.
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Follow a sick day management plan that you and your physician establish.
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Make sure you stay well-hydrated, especially if you are feverish or vomiting.
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Check your insulin pens and pump daily to make sure they are working properly.
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Contact your doctor immediately if your blood sugar stays high despite your treatment.
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Inform your family and caregivers about the symptoms of DKA.
Does Health Insurance Cover Diabetic Ketoacidosis?
Yes. Most health insurance policies in India cover DKA treatment, including hospitalisation expenses, as per IRDAI norms for diabetes-related conditions.
Comprehensive health insurance plans usually include all the costs of ICU care, IV insulin infusions, electrolyte correction, diagnostic tests, and doctor consultations in the inpatient coverage. DKA is a life-threatening condition that requires hospitalisation and critical care, including continuous monitoring.
Some key points to remember regarding insurance coverage are:
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Diabetes is treated as a pre-existing condition (PED) in most Indian health insurance policies.
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Waiting periods vary among insurance providers and may extend up to 36 months for PED conditions.
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However, if DKA is encountered as a medical emergency in a person not having a known history of diabetes, then it may be covered without any waiting period, depending on the policy.
Read your policy documents carefully and contact your insurance provider to be sure about the cover and waiting period involved.
How Much Health Insurance Coverage Is Needed for DKA Treatment?
The expense to manage DKA in India would vary with the severity of the episode, hospital type, and location of treatment. In private hospitals, the cost of standard ICU care ranges from ₹15,000 to ₹30,000 per day.
An average 3-7 days hospitalisation with ICU care, diagnostics, IV fluids, insulin, etc., can amount to anywhere between ₹2 and ₹5 lakh or even more. For diabetes patients, a sum insured of ₹5 - ₹10 lakh usually suffices for typical hospitalisation, tests, and emergency care needs.
For diabetics experiencing frequent DKA episodes, managing Type 1 diabetes, and other existing conditions like kidney disease, heart disease, neuropathy, etc., coverage of ₹15 to ₹20 lakh is advisable.
Compare available plans and check the inclusion of ICU coverage and the existing disease clause to ensure the policy meets your requirements.
FAQs
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Q1. What is diabetic ketoacidosis?
Ans: Diabetic ketoacidosis (DKA) occurs when your body is deficient in insulin and begins to break down body fat for energy. This causes a buildup of ketones in the blood, which increases the acidity of the blood, known as metabolic acidosis. -
Q2. What are the early signs of DKA?
Ans: The early signs of DKA include an increased urge to drink water, frequent urination, tiredness, nausea, and high blood sugar levels. As the condition progresses, you may notice a fruity smell to your breath, vomiting, and pain in your abdomen. Seek immediate medical attention if you develop these symptoms. -
Q3. Can DKA occur in Type 2 diabetes?
Ans: Yes. While DKA is more typical in Type 1 diabetes, it can affect Type 2 diabetics, especially when there is a severe illness or infection, or if they are taking certain medications like SGLT-2 inhibitors.
