Diabetic ketoacidosis is a decompensated form of diabetes mellitus associated with insulin deficiency. The disease is accompanied by an increase in the level of glucose and ketone bodies in the blood. DKA occurs as a result of a metabolic failure in patients with diabetes and is the most common complication.
What is ketoacidosis
"Acidosis" is translated from Latin as "sour" and means a shift in the acid-base balance of the body towards increased acidity. Since the reason for this process is an increase in the concentration of ketone bodies, the prefix "keto" is added to the word "acidosis".
What is the relationship between dysregulation of metabolic processes and diabetes? Let's try to explain. Normally, the main source of energy is glucose, which enters the body with food. The missing amount is compensated by glycogen accumulating in the muscles and liver.
Since glycogen reserves are limited, and its volume is calculated for about a day, it is the turn of fat deposits. Fat is broken down to glucose, and thus compensates for its deficiency. Fat breakdown products are ketones, or ketone bodies - acetone, acetoacetic acid and beta-hydroxybutyric acid.
Increasing the concentration of acetone can occur during exercise, diets, with an unbalanced diet with a predominance of fatty foods and the minimum amount of carbohydrates. In a healthy body, such a process is not detrimental due to the kidneys, which in a timely manner remove the ketone bodies, and the PH balance is not disturbed.
A patient with diabetes mellitus must be instructed how to manage his illness: he should learn to control sugar levels and calculate insulin dosage depending on the food taken.
Diabetic ketoacidosis develops very quickly, even with normal nutrition and lack of physical activity. The reason lies in the lack or complete absence of insulin, because without it, glucose cannot penetrate into the cells. There is a situation of "hunger among the abundance", when glucose is enough, and there are no conditions for its use.
Fat and glycogen cannot influence the process, and the level of glucose continues to grow. Hyperglycemia is increasing, the rate of fat splitting increases, and as a result, the concentration of ketone bodies becomes threatening. With an increase in the renal threshold, glucose enters the urinary system and is actively excreted by the kidneys.
The kidneys work at the limit of their capabilities, and sometimes they do not cope, thus a significant amount of fluid and electrolytes are lost. Due to the substantial loss of fluid, the blood thickens and oxygen starvation occurs in the tissues. Tissue hypoxia contributes to the formation of lactic acid (lactate) in the blood, which is fraught with the development of lactic acid coma-lactate acidosis.
Normally, the PH of the blood is on average 7.4, with its value below 7 there is a direct threat to human life. Diabetic ketoacidosis can lead to such a decrease in just a few hours, and ketoacidotic coma occurs within a day or a little more.
To provoke a state of acute decompensation can lack of insulin in diabetes of any type. Type 1 diabetes mellitus is usually accompanied by absolute insulin deficiency. In type 2 diabetes, relative insulin deficiency develops.
Diabetic ketoacidosis is often the first symptom of type 1 diabetes, if the patient does not yet know that he is ill and does not receive treatment. That is how primary diabetes is diagnosed in about a third of patients.
Ketoacidosis occurs only with a strong insulin deficiency and a sharp increase in blood glucose.
A number of factors can provoke the development of ketoacidosis, namely:
- errors in taking insulin - incorrect dosage, use of drugs that have expired, unexpected failure of an insulin syringe or pump;
- medical error - prescription of tablets for lowering blood sugar with the obvious need of the patient for insulin injections;
- taking insulin antagonist drugs that increase blood sugar - hormones and diuretics;
- violation of the diet - an increase in the intervals between meals, a large number of fast carbohydrates in the diet;
- treatment with neuroleptics that reduce insulin sensitivity;
- alcohol dependence and nervous disorders that prevent adequate therapy;
- use of alternative, folk remedies instead of insulin therapy;
- related diseases - endocrine, cardiovascular, inflammatory and infectious;
- injuries and surgeries. After surgery on the pancreas in people who have not previously suffered from diabetes, the insulin production process may be disrupted;
- pregnancy, especially accompanied by severe toxicosis with frequent vomiting.
In 25 out of 100 patients, the cause of ketoacidosis in diabetes mellitus is idiopathic, since it is not possible to establish a connection with any of the factors. Increased need for insulin may occur in children of school age and adolescents during periods of hormonal adjustment and nervous overstrain.
There are frequent cases and intentional refusal of insulin, having suicidal goals. In this way, young people with type 1 diabetes often try to kill themselves.
Classification and symptoms
Ketoacidosis develops in three stages:
- ketoacidotic precoma, stage 1;
- the onset of ketoacid coma, stage 2;
- complete ketoacidotic coma, stage 3.
In most cases, it takes about 2.5-3-3 days from the first to the last stage. There are exceptions, when the coma comes in no more than a day. With the increase in blood glucose and other metabolic disorders, the clinical picture is becoming more pronounced.
Symptoms of diabetic ketoacidosis are divided into early and late. The first signs of hyperglycemia appear:
- dry mouth, feeling of constant thirst;
- frequent urination;
- weight loss and weakness.
Diabetic ketoacid coma is one of the types of hyperglycemic coma and occurs in about 40 patients out of a thousand.
Further, there are characteristic symptoms of increased ketone production - a change in the respiratory rhythm, called Kussmaul breathing. The person begins to breathe deeply and noisily, while breathing in the air less often than usual. In addition, there is a smell of acetone from the mouth, nausea and emetic urge.
All of the above symptoms are an indication for emergency hospitalization. Since manifestations of ketoacidosis are similar to other diseases, the patient is often brought to a surgical or infectious hospital. Therefore, it is very important to preliminarily measure the patient's blood sugar and check for the presence of ketone bodies in the urine.
In patients with ketoacidosis, complications can occur - pulmonary edema, thrombosis of various localization, pneumonia and brain edema.
Based on complaints and examination of the patient, the primary diagnosis and the presence of systemic diseases that aggravate the course of ketoacidosis are established. During the inspection, characteristic features are observed: the smell of acetone, pain on palpation of the abdomen, inhibited reactions. Blood pressure is usually low.
Laboratory tests of blood and urine are conducted to confirm the diagnosis and differential diagnosis. When the content of glucose in the blood is more than 13.8, we can speak about the development of ketoacidosis, the value of this indicator from 44 and above indicates the precomatose state of the patient.
The level of glucose in urine with ketoacidosis is 0.8 and higher. If the urine has ceased to stand out, then special test strips are used with blood serum applied on them. Elevated levels of urea in the blood indicate impaired renal function and dehydration.
The development of ketoacidosis can be judged by the level of amylase, an enzyme of the pancreas. Her activity will be higher than 17 units / hour.
For ketoacidosis, infusion therapy with isotonic sodium chloride is performed and insulin injections are given.
Since diuresis increases under the influence of hyperglycemia, the level of sodium in the blood drops below 136. In the early stages of diabetic ketoacidosis, the rate of potassium increases, which can exceed 5.1. With the development of dehydration, the concentration of potassium gradually decreases.
Blood bicarbonates play the role of a kind of alkaline buffer that maintains the acid-base balance in normal conditions. With a strong acidification of the blood with ketones, the amount of bicarbonate decreases, and in the final stages of ketoacidosis it can be less than 10.
The ratio of cations (sodium) and anions (chlorine, bicarbonates) is normally about 0. With increased formation of ketone bodies, the anion interval can increase significantly.
By reducing the amount of carbon dioxide in the blood to compensate for the acidity, cerebral circulation is disturbed, which can lead to dizziness and fainting.
If necessary, patients are assigned an electrocardiogram to rule out a heart attack due to dehydration. To exclude a pulmonary infection, chest x-rays are done.
Differential (distinctive) diagnostics is carried out with other types of ketoacidosis - alcoholic, hungry, and lactic acid (lactic acidosis). The clinical picture may have similarities with poisoning with ethyl and methanol alcohol, paraldehyde, salicylates (aspirin).
Therapy of diabetic ketoacidosis is carried out only in stationary conditions. Its main areas are as follows:
- insulin replacement therapy;
- infusion therapy - rehydration (replenishment of lost fluid and electrolytes), PH correction;
- treatment and elimination of associated diseases.
Acid-base balance, or PH - is one of the most important factors that determine the likelihood of many diseases; when it oscillates in one direction or another, the activity of organs and systems is disturbed, and the body becomes defenseless
During his stay in the hospital, the patient is constantly monitored vital signs according to the following plan:
- rapid glucose tests - every hour, until the sugar index drops to 14, after which blood is taken once every three hours;
- urine tests - 2 times a day, after two days - 1 time;
- blood plasma for sodium and potassium - 2 times a day.
To control the urinary function, a urinary catheter is installed. When the patient regains consciousness, and normal urination is restored, the catheter is removed. Blood pressure, pulse and body temperature are measured every 2 hours or more.
Using a special catheter with a transmitter, central venous pressure is also controlled (blood pressure in the right atrium). Thus, the state of the circulatory system is assessed. An electrocardiogram is performed either continuously or once a day.
It is important to know that even before hospitalization a diabetic needs to inject sodium chloride intravenously in a volume of 1 liter / hour and short insulin intramuscularly — 20 units.
Insulin therapy is the main method that can eliminate the pathological processes that led to the development of ketoacidosis. To raise the level of insulin it is administered in short doses of 4-6 units hourly. This helps to slow down the breakdown of fats and the formation of ketones, and consequently, the release of glucose by the liver. As a result, glycogen production is increased.
Insulin is also administered to the patient in a drip way in a continuous mode. To avoid insulin adsorption, human serum albumin, sodium chloride solution and 1 ml of the patient's own blood are added to the treatment solution.
Insulin doses can be adjusted depending on the measurement results. In the absence of the expected effect in the first two or three hours, the dose is doubled. However, it is strictly forbidden to reduce blood sugar levels too quickly: a decrease in the concentration of more than 5.5 mol / l per hour threatens the development of cerebral edema.
To replenish fluid reserves, infusions of 0.9% saline with sodium chloride are carried out. In case of elevated sodium in the blood, 0.45% solution is used. With the elimination of fluid deficiency, kidney function is gradually restored, and the blood sugar level decreases faster. Excess glucose begins to be actively excreted in the urine.
With the introduction of saline, it is necessary to monitor the CVP (central venous pressure), because they depend on the amount of urine. Therefore, even in the case of substantial dehydration, the volume of injected fluid should not exceed the volume of urine excreted by more than a liter.
Type 2 diabetes occurs in 9 patients out of 10 and most often affects the elderly
The total volume of injected saline per day should not exceed 10% of the patient's weight. With a decrease in the upper blood pressure indicators (less than 80), blood plasma is infused. With a deficiency of potassium, it is administered only after the restoration of urinary function.
During treatment, potassium levels will not rise immediately, due to his return to the intracellular space. In addition, during the introduction of saline occurs natural loss of electrolytes in the urine. However, after the recovery of potassium in the cells, its content in the bloodstream is normalized.
Correction of acidity
With normal values of blood sugar and a sufficient supply of fluid in the body, the acid-base balance gradually stabilizes and shifts to alkalinity. The formation of ketone bodies is stopped, and the restored excretory system successfully copes with their disposal.
That is why no additional measures are required: the patient should not drink mineral water or baking soda solution. Only in some cases, when the acidity of the blood decreases to 7, and the level of bicarbonates - to 5, is shown an infusion introduction of sodium bicarbonate. If blood alkalization is used at higher rates, the effect of therapy will be reversed:
- increased tissue hypoxia and acetone content in the spinal cord;
- pressure will decrease;
- deficiency of calcium and potassium will increase;
- insulin function is impaired;
- the rate of formation of ketone bodies will increase.
The history of the disease "diabetes" began with the history of mankind. People learned about it before our era, as evidenced by the surviving manuscripts of ancient Egypt, Mesopotamia, Rome and Greece.In those early years, treatment was limited to herbs, so patients were doomed to suffering and death.
Beginning in 1922, when insulin was first used, it was possible to defeat a terrible disease. As a result, a multimillion-dollar army of patients needing insulin was able to avoid premature death from diabetic coma.
Today, diabetes and its complications, including ketoacidosis, are treatable and have a favorable prognosis. However, it is important to remember that medical care must be timely and adequate, because when it is delayed, the patient quickly falls into a coma.
In order to prevent the development of diabetic ketoacidosis and to maintain the quality of life at a decent level, it is necessary to properly use devices designed to inject insulin, and to keep the blood sugar level under constant control. Be healthy!