The Ins and Outs of DKA
When putting a new patient on an insulin pump, I spend a lot of time making certain that they are familiar with diabetic ketoacidosis and its effects. First I start by posing the question, "What is insulin?" Insulin is a growth hormone and it is essential for all cells to grow and function. Without insulin, no cells in the body can function and will self-destruct. I explain how this destruction will release acid throughout the body and then ask, "Do you have any idea what this would feel like?"
The symptoms would be:
- Stomach upset with or without nausea
- Nagging headache
- Muscle or joint aches
In other words, exactly like having the flu.
This flu-like feeling is a result of the cell destruction and is called ketoacidosis. If untreated, ketoacidosis will eventually cause everything in the body to stop working. Unlike a car falling from a cliff, you can stop this from happening by recognizing that you are headed towards the cliff and change your direction. In diabetes we can change the direction or correct ketoacidosis with insulin, fluids, and eventually sugar.
When these acids from cell destruction are present, insulin does not work as well as it would at other times. Because of this, the blood glucose tends to be higher than it normally would be. In order to know what to do therefore, it is a basic law of survival for somebody with diabetes who feels like they have the flu and/or has a blood glucose over 250 to check and see if ketones are present.
Checking for ketones is easier than checking your blood glucose. It's done by placing a piece of specially treated paper called a urine ketone stick in your urine. Much like pregnancy tests, a change in color means that something is going on.
You have ketones if the color changes. This tells you what to do next: immediately take an injection of regular insulin and call your doctor.
Your next step is to find out why this is happening. Since lack of insulin can be a cause, at this point you should check your pump. Routinely, we ask our patients to take up to as much as 5-10 units of regular insulin every half hour and to drink lots of sugar-free liquids. The amount of insulin you need to take should be decided beforehand when you ask your physician how much to take if you have ketones.
Once the blood glucose is below 200, we reduce the amount of insulin to 5 units per hour. We can now switch from non sugar containing liquids to drinks that have sugar, i.e., 2 large glasses of Gatorade per hour or 2 cans per hour of regular soda. In the meantime, with all this liquid going in, there's bound to be lots of liquid (urine) going out; we use this liquid going out to check for ketones every hour. Once the urine ketones are negative, you're normal and back to your regular routine.
Alan Marcus, MD, FACP
President, South Orange County Endocrinology
Laguna Hills, CA
