American Diabetes Association Complete Guide to Diabetes. American Diabetes Association

often preventable—emergency can arise when blood glucose levels rise. Diabetic ketoacidosis, also called DKA, occurs when you don’t have enough insulin. It is mostly a problem for people with type 1 diabetes. A person with diabetes may have such low levels of insulin that his or her liver may produce unchecked levels of glucose and ketones, especially during illness or stress. It can occur in people with type 1 diabetes who have not yet been diagnosed.

      Diabetic ketoacidosis can start innocently enough; you miss a dose of insulin, the insulin you’ve been using has gone bad, or your insulin pump tubing gets blocked. The lack of insulin leads to an undetected high blood glucose level, which can progress to a coma, shock, pneumonia, difficulty breathing, and even death.

      Diabetic ketoacidosis can occur during periods of stress or illness, when the body releases hormones that promote the release of stored glucose and block the effects of insulin. Sometimes when you are sick and can’t eat, you may think, “I shouldn’t take insulin today.” But your body still needs insulin to cover its 24-hour insulin needs, even if you aren’t eating. Plus, you are likely producing extra glucose. So, in addition to your usual dose of insulin, you may actually need extra insulin. Drinking plenty of fluids will also help. Talk with your health care providers ahead of time about a plan of action for dealing with ketoacidosis and how to prevent it when you are stressed or ill.

      Signs of DKA

      • High blood glucose above 240 mg/dl and not falling

      • Classic signs of hyperglycemia: intense thirst, dry mouth, need to urinate frequently

      • Lack of appetite or pains in your stomach

      • Vomiting or nausea

      • Blurry vision

      • Fever or warm, dry, or flushed skin

      • Difficulty breathing

      • Feeling of weakness

      • Sleepiness

      • A fruity odor on your breath

Testing for Diabetic Ketoacidosis

      You can use a test strip to measure the amount of ketones in your urine. Urine test strips are available over the counter, and you can find out more about using them in chapter 7. Some blood glucose meters also check for ketones.

      You’ll want to test your urine for ketones whenever your blood glucose is over 240 mg/dl or you feel ill. If your urine shows trace or small amounts of ketones, it’s a sign that you need more insulin or carbohydrate.

      When to Test for Ketones

      • If your blood glucose is over 240 mg/dl and not falling

      • When you are ill, especially if you have a high fever, bouts of vomiting, or diarrhea

      • When you have severe fatigue, fruity breath, breathing difficulties, or a hard time concentrating

      • During pregnancy, if your blood glucose is over 200 mg/dl or as your health care provider recommends

      How to Check for Ketones in Urine

      Equipment

      • Ketone test strip

      • Cup or a clean container to contain the urine, if desired

      • Watch or other timing device

      Instructions

      1. Dip a ketone test strip in a urine sample or pass it through the stream of urine.

      2. Time test according to the directions on the package.

      3. The strip will change colors if ketones are present. Compare test strip to package color chart.

      4. Record the results.

      5. Contact your provider as recommended based on your results.

      If Your Urine Shows Moderate or Large Amounts of Ketones

      • Call your health care team immediately or use the plan that you and your health care team have already put in place.

      • You probably need to take extra rapid- or short-acting insulin right away.

      • Drink plenty of sugar-free fluids to prevent dehydration.

      • Seek emergency help at once if your ketones do not promptly go down or if you are vomiting and can’t stop.

      • Make sure those who spend time with you know what to look for and what to do if you have signs of diabetic ketoacidosis.

      Illness calls for more frequent blood glucose monitoring and urine testing for ketones. Do both at least every 4 hours until you’re feeling better. Check your urine for ketones any time you feel queasy or are vomiting (even if your blood glucose isn’t high). A buildup of ketones can cause nausea.

      Pregnant women should also test for ketones frequently. Daily urine ketone testing can help detect elevated levels and prevent diabetic ketoacidosis, which can be very dangerous for the developing baby.

      Blood Ketone Testing

      Your doctor may prefer that you check for ketones in your blood rather than in your urine. Testing ketone levels in the blood actually yields more accurate results than checking ketones in urine. Usually, blood ketone levels are checked by drawing blood and testing the sample in a lab—obviously, this is something done at a clinic or hospital. However, some newer blood glucose meters can check blood ketone levels in addition to blood glucose levels, making this test easy to perform at home.

      Type 2 Diabetes and Hyperosmolar Hyperglycemic Syndrome

      People with type 2 diabetes have less dramatic swings in blood glucose levels compared with people with type 1 diabetes, in general. However, people with type 2 diabetes can sustain high blood glucose levels over prolonged periods without even knowing it. This can wear on the body and may cause diabetes complications. You can guard against chronic hyperglycemia by monitoring your blood glucose levels regularly.

      Acute hyperglycemia can occur in people with type 2 diabetes and is life threatening. Hyperglycemia in people with type 2 diabetes does not usually produce ketones. But blood glucose levels can soar to over 600 mg/dl and even as high as 1,000 mg/dl. This sometimes happens before diabetes is diagnosed. Extreme hyperglycemia can cause a coma.

      Hyperosmolar hyperglycemic syndrome (HHS) occurs almost exclusively in people with type 2 diabetes. It can happen to people who manage their diabetes with food and exercise only and those who take diabetes medications.

      One-third of all cases of HHS are caused by undiagnosed diabetes. HHS results from stress, infections, heart attacks, strokes, corticosteroid medications, and even diuretics. Sometimes something as simple as not being able to get a drink of water can contribute to developing HHS. It occurs more often in people who have restricted mobility, such as the elderly, or in people who cannot take good care of their bodies. Also, as you age, your sense of thirst diminishes, and it’s harder to sense the need to drink enough fluids.

      HHS occurs because rising blood glucose levels cause you to urinate more and become dehydrated. This process may go on for days and weeks. Extreme dehydration eventually leads to confusion and inability to get a drink or make it to the toilet. The blood gets thicker with more glucose and less fluid. Eventually, the severe dehydration leads to seizures, coma, and death.

      Signs of HHS

      • Dry, parched mouth

      • Extreme thirst, although this may gradually disappear

      • Sleepiness or confusion

      • Warm, dry skin with no sweating

      • High blood glucose. If it’s over 300 mg/dl on two readings, call your health care team; if it’s over 500 mg/dl and not falling, have someone take you to the hospital immediately.

      If