Ketoacidosis And Hyperglycemic Hyperosmolar Syndrome
Severe high blood sugars, ketosis (the presence of ketones prior to acidification of the blood), and ketoacidosis (DKA) are serious and potentially life-threatening medical problems which can occur in diabetes. High blood sugars become life-threatening in Type 1 or long-term Type 2 diabetes only when that person does not receive enough insulin from injections or an insulin pump. This can be caused by skipping insulin or not receiving enough insulin when large amounts are required due to an infection or other major stress.
Ketoacidosis surprisingly occurs almost as often in Type 2 diabetes as it does in Type 1. However, people with Type 2 diabetes also encounter another dangerous condition called hyperglycemic hyperosmolar syndrome, which is roughly translated as thick blood due to very high blood sugars. Here, coma and death can occur simply because the blood sugar is so high. The blood will have ketones at higher levels but does not become acidotic. HHS usually occurs with blood sugar readings above 700 mg/dl (40 mmol) as the brain and other functions begin to shut down.
When insulin levels are low, the body cannot use glucose present at high levels in the blood. The body then starts burning excessive amounts of fat which causes the blood to become acidic as excess ketone byproducts are produced. Even though the blood pH which measures acidity only drops from its normal level of 7.4 down to 7.1 or 7.0, this small drop is enough to inactivate enzymes that depend on a precise acid-base balance to operate.
High blood sugars and ketoacidosis can be triggered by:
- not taking insulin
- severe infection
- severe illness
- bad insulin
In Type 1 diabetes, ketoacidosis often occurs under the duress of an infection, and is also frequently present when a person first comes down with the disease between the time when they stop producing their own insulin and begin to inject insulin from the outside. In Type 1 diabetes, it can also occur whenever insulin delivery becomes interrupted for several hours (about 4.5 hours on Humalog or Novolog) on a pump, or after a day or so of missed injections. In Type 2 diabetes, ketoacidosis and HHS usually occur when there is a major stressful event, such as a heart attack or pneumonia.
In children and adolescents with Type 1 diabetes, ketoacidosis can also be triggered by growth spurts which make the body require more insulin, although blood sugar tests generally let parents know that additional insulin is required before the situation becomes that severe. If an infection or illness is triggering the problem, high blood sugars will be difficult to bring down until the underlying problem is dealt with.
High blood sugars may exist for weeks, months, or years without triggering ketoacidosis if enough insulin is present in the blood. Ketoacidosis begins only when insulin levels in the blood are quite low compared to need.
When insulin levels drop, the body starts burns more fat and produces more ketones, even though glucose levels are high in the blood. Burning fat might sound like a good thing, especially if you are trying to lose weight. But this excessive use of fat is quite unhealthy because the activity of hundreds of essential enzymes is affected. Ketones are a normal byproduct of fat metabolism, but when created in excess they acidify the blood, triggering nausea and vomiting.
Vomiting in the presence of very high blood sugars quickly leads to a dangerous state of dehydration. This combination is quite serious and can cause death. In a recent study from Malmo, Sweden, among 4,097 recently diagnosed people between 15 and 34 years of age, the death rate was 2.3 times higher in those with Type 1 diabetes and 4.1 times higher in those with Type 2. Among 58 deaths in this group, 11 deaths were due to ketoacidosis, with an additional 7 deaths related to hypoglycemia (J Intern Med, Mar 2001; 249(3): pgs. 263-270). Overall, the death rate when ketoacidosis occurs is 10%, or one in every ten cases, although most deaths occur in the elderly.
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