Causes of Diabetic Keto Acidosis (DKA)

So what is it about a sick-day that makes a person at higher risk for DKA?

DKA rests on a three legged stool comprised of: Physical stress Lack of insulin Dehydration   And like any 3 legged stool it is safe to use when all three legs are strong. But weaken one leg and it’s definitely unstable, weaken two legs and you’re probably in trouble, weaken all three and you are absolutely going to get seriously hurt.

Let's take a look at some of the factors which make up this three legged stool:

The first leg is physical stress:

Physical stress can mean illness, intense workouts, deprivation, or trauma.   Avoid insulin reductions in these situations.   Ketone size can indicate infection severity.   Treatments may take longer to be fully effective.

 

Anytime we put our body under stress it will try to switch from a carbohydrate metabolism to a fat metabolism (our body assumes that stress means we are in danger from something like starvation, so it rallies its internal energy factory rather than depending on an unreliable external source). When we burn fats, we produce ketones. An interesting note is that this is not only on sick days, as most people will show trace to small ketone production from a high intensity workout, where our body is put under sudden stress and that “survival” mode kicks in. This is another good reason not to reduce insulin too far for too long to prevent activity related hypoglycemia, as DKA risk increases under physical stress).

Since illness is the very definition of physical stress the illness itself causes ketone production. As a general rule the more severe the infection the higher the ketone production. For example pneumonia and sepsis will produce dangerously high levels of ketones all by themselves and these are disease states we simply cannot survive without medical intervention. But some infections are also known for causing high ketone levels, particularly UTIs, Strep throat, dental infections, and many more. For this reason, aggressively treating infections is important for people with diabetes.

3 Rules of Sick-Days

1. Check Ketones Often (every 3-4hr)   2. DO NOT reduce insulin with ketones   3.  In unable to check for ketones, assume they are present and see rule #2!

Lack of insulin: Insulin pump users are familiar with this cause of DKA, if we do not have sufficient insulin to meet our body’s metabolic needs we can’t use carbohydrates for energy, so we switch to fat metabolism. Fat molecules are essentially glucose strands that are linked by a fatty acid  that we call a ketone (A gross over simplification but T1U does not have an organic chemistry professor at this time) When the body must use fats for energy the ketones are left behind in the blood stream and can build up rapidly. Because these are acids they make the blood more and more acidic until the pH balance is thrown off and the body’s attempts to compensate for this imbalance become destructive.(Acidosis)

So maintain insulin levels sufficient to meet the body’s basic needs is critical to living safely with diabetes. Taking care on sick days to take our injections on time and to keep our pumps connected and sites working effectively is extremely important! During times of illness these basic metabolic needs will often increase and so we need more insulin to prevent ketone production (sometimes this comes with higher blood sugars, but we can even see ketones without a rise in blood sugar when we are sick!)

This brings me to the three golden rules of sick days

1.-check for ketones

2.-never reduce insulin in the presence of ketones

3.-if unable to check for ketones, assume they are present and see rule 2!

(Care providers, I make sure young people can recite this in their sleep before they head off on their own!)