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Understanding the True Causes of Diabetic Ketoacidosis (DKA)

Recently here at IDS we shared our personal most hated Myths in diabetes education (or perhaps MISEDUCATION). Mine was that Diabetic Keto Acidosis (DKA) is caused by elevated blood sugars.

This miseducation is upsetting, because not only does it put patients at risk, it is indicative of a far deeper problem, DOCTORS NOT UNDERSTANDING WHAT CAUSES DKA!

Rather than understanding the mechanism of action (insufficient insulin, often coupled with dehydration and/or physical stress such as illness causing a rapid catabolic state that increases ketones and decreases blood pH swiftly) Doctors simply lean on diagnostic parameters to guide diagnosis and treatment of DKA, and up to now that has included high blood sugars. This means that when people with preexisting diabetes go to the hospital in early stages of DKA with high ketones, but BGs under 250mg/dL they are often untreated, or their care is significantly delayed to the point of additional major medical repercussions.

Diabetic Keto Acidosis

In a recent article from Medscape: Nurses, independent diabetes industry consultant Charles Alexander, MD “The problem is that medical education for many years has taught us that DKA is a condition of high blood glucose, but it may not be

A new consensus report by the American Diabetes Association (ADA) and The European Association for the Study of Diabetes (EASD) is finally taking aim at addressing these diagnostic standards to place emphasis back on the acidosis, instead of the blood sugars.

What is Metabolic Acidosis?

Metabolic acidosis is now defined as a pH < 7.3 and/or a bicarbonate concentration < 18 mmol/L, up from 15 in some prior guidelines including the UK’s.

Also, anion gap has been removed from the main definition but, the document will say, can still be used in settings where ketone testing is unavailable. BG screening levels have dropped from 250 mg/dl to 200 mg/dl in patients with preexisting diabetes (However this does not specify by type of diabetes.)

These blood glucose levels may still be too high as patients on medications such as SGLT2s may not see a significant blood sugar rise even with large ketones, and patients on insulin may be taking insulin sufficient to suppress elevated blood sugars but may not have sufficient hydration to clear ketones produced by physical stress of illness.

“Approximately 10% of DKA occurs with euglycemia or near-normoglycemia,” noted co-author Shivani Misra, MD, PhD, senior clinical lecturer and honorary consultant in Metabolic Medicine at Imperial College, London, United Kingdom.”

What should you tell emergency room doctors if you think you are experiencing DKA?

Any patient with a history of diabetes who is experiencing illness and showing signs or symptoms of DKA such as:

  • stomach pain
  • nausea
  • vomiting
  • lethargy
  • shortness of breath
  • mentation or moodchanges

Should be assumed to be ins DKA and fully tested for DKA regardless of blood sugar state.

Insulin dependent patients should all have proper education on DKA prevention including actual causes and preventative measures.

Unfortunately along with this education here at IDS we include phrases to use at the ED to let them know that you know what you are talking about and what to look for like:

  1. Please check my pH and bicarb levels.
  2. This is not metabolic acidosis I eat at least 100 grams of carb per day.
  3. My blood sugars are not elevated because I have not been able to keep in foods. Dehydration, physical stress and lower insulin levels than needed are causing DKA.
  4. Please screen for DKA even though my BG is below 250. Meanwhile please start a bag of normal saline for hydration and to help be urinate out ketones and please place and EKG monitor while I wait. (most emergency departments have standing order protocols in place that allow nursing staff to start a normal saline IV without the patient having been seen by the doctor for the purposes of maintaining blood pressure or providing emergency hydration.)

And of course, educate and advocate.

Educate your physicians and discuss your emergency sick day management plan with them. Asking your diabetes clinical team to advocate for people with diabetes with your local emergency departments for better education and response is also a great way to help yourself and the entire diabetes community.

For more information on the consensus statement and new DKA and HHS guidelines: New Hyperglycemia Emergency Guidance Updates DKA Definition