Severe Highs, Ketosis, and Ketoacidosis (DKA)

Overview
Symptoms and Detection
Treatment

Severe high blood sugars, ketosis, and diabetic ketoacidosis (also called DKA) are severe and potentially life-threatening medical problems. High blood sugars can happen when insulin levels are low. Ketosis occurs when those low insulin levels cause the body to burn fat, producing ketones in the blood. DKA begins when the rising ketone levels cause the blood to turn acidic, triggering nausea, and vomiting. Vomiting, along with very high blood sugars, quickly leads to a dangerous state of dehydration…if not treated promptly, this severe combination can kill.

Ketosis or DKA must be taken seriously and treated quickly. If you or a loved one is experiencing ketosis symptoms or frank DKA, begin treatment  right away.

Overview

How does it happen?

Insulin is the key that allows glucose (sugar) in the blood to enter the body’s cells and provide energy. When insulin is not present, or levels are too low, the body can’t use the glucose in the blood. The body starts to release and burn more fat to supply the missing energy. Burning fat might sound good if you’re trying to lose weight, but with DKA, this produces excess ketone byproducts that turn the blood acidic. Enzymes require a precise acid-base balance to operate. Even though the blood becomes only slightly more acidic (The pH might drop from7.4 to 7.1 or 7.0.), this is enough to inactivate critical enzymes. This can send you into a dangerous, possibly life-threatening condition, worsened by dehydration as the excess glucose carries water into the urine. 

Why does it happen?

High blood sugars, ketosis, and ketoacidosis can be triggered by:

  • New Type 1 diabetes
  • Severe infection
  • Heart attack, stroke, or severe illness
  • Insulin doses that are skipped or are too low
  • Non-delivery from an infusion set or pump failure
  • Growth spurts in children or adolescents causing increased insulin need
  • Taking certain medications like corticosteroids or prednisone
  • Severe stress
  • Insulin that has become degraded from heat, cold, or age

Ketoacidosis happens in about 35% of new-onset cases of Type 1 diabetes. The pancreas is unable to produce insulin, and the body starts burning fat to survive. It can also occur in Type 1 at any point when the glucose is too high. For example, DKA can begin if insulin delivery becomes interrupted for several hours on a pump, or after a day or so of missed injections.

In children and adolescents with Type 1 diabetes, ketoacidosis can also be triggered by growth spurts, making the body require more insulin. However, blood sugar tests generally let parents know that additional insulin is needed before the situation becomes that severe. Suppose an infection or illness triggers the problem. In that case, extra insulin will be required, but the high blood sugars will be challenging to bring down until the underlying problem is dealt with.

Surprisingly, ketoacidosis occurs almost as often in Type 2 diabetes as it does in Type 1.  Those with Type 2 diabetes are also at risk for another hazardous condition called hyperglycemic hyperosmolar syndrome (HHS). This term roughly translates as thick blood due to very high blood sugars. Here, coma and death result from severe dehydration caused by very high glucose levels. Some elevation of ketones may be detected in the blood, but the blood does not become acidic.

In Type 2 diabetes, ketoacidosis and HHS usually occur when there is a major stressful event, such as a heart attack or pneumonia. HHS usually occurs with blood sugar readings above 700 mg/dl (40 mmol), as the brain and other functions begin to shut down.

Euglycemic or atypical ketoacidosis is a form of DKA that can be difficult to recognize. It starts when the glucose is less than 200. Severe stress releases cortisol, glucagon, catecholamines, and growth hormone that can mobilize large quantities of fat and raise ketone levels in the blood. Even fasting when the insulin level is low can cause this.

Rates of DKA and euglycemic ketoacidosis have increased in Type 1 and Type 2 diabetes with the increasing use of SGLT-2 inhibitors. SGLTs like Farxiga (dapagliflozin), Invokana (canagliflozin), and Jardiance (empagliflozin) raise growth hormone levels and lower glucose levels. Rather than having glucose levels rise when insulin is short, SGLT-2 inhibitors pass excess glucose into the urine. These medications are not approved for Type 1 diabetes because poor metabolic control due to a low insulin level can be hidden by somewhat reasonable glucose readings. Routine ketone testing is advised when using these medications.

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 the need.

After an episode of ketosis or DKA, analyze why it happened and correct those reasons to prevent a future event. It should raise a red flag any time ketoacidosis occurs unless there is an apparent reason, such as an illness or an infection. Insulin doses may be too low, or you may need to know more about using insulin for blood sugar control. Discuss any problems you have regarding high blood sugars or ketoacidosis with your physician so issues can be quickly resolved and prevented from happening again. Once you experience DKA, you won’t want to repeat it.

Symptoms

Test for ketones and follow the treatment plan  below if you have any early symptoms. For late symptoms, immediate treatment in an emergency room is required to prevent coma and possible death.

Early Signs, Symptoms:
(Begin treatment at home, call doctor if no improvement)
Late Signs, Symptoms:
(Go to ER or call 911)
  • high glucose reading (over 300 mg/dL, or over 250 mg/dL without a clear reason)
  • nausea or abdominal pain* (even without high glucose)
  • vague flu-like symptoms
  • increased thirst and dry mouth
  • excessive urination
  • increased hunger
  • excessive tiredness or weakness
  • confusion
  • dry skin
  • leg cramps
  • acetone or fruity odor to the breath*
  • upset stomach*
  • vomiting*
  • severe abdominal pain
  • shortness of breath
  • sunken eyeballs
  • very high blood sugars
  • rapid pulse
  • rapid breathing
  • low blood pressure
  • unresponsiveness, coma
* these are more specific for ketoacidosis than hyperosmolar syndrome (Adapted from Pumping Insulin, 6th Edition)

Symptoms for hyperglycemic hyperosmolar syndrome are linked to dehydration rather than acidosis. A fruity odor to the breath and stomach upset is less likely.

How To Detect Ketones

After ketones are formed from fat metabolism, they collect in the blood and are excreted into the urine. There are two ways to test for and measure ketones at home:

In the Urine with test strips like Ketostix (measures ketones only) or Ketodiastix (measures ketones and glucose in the urine). Ketone strips should always be kept on hand, stored in a dry area, and replaced as soon as they become outdated. Most people rarely need to use them, so strips individually wrapped in foil for freshness are handy.

In the Blood with specialized meters that measure sugar and ketones in the blood, like the Precision XtraNova Max Plus, or Fora 6 Connect. This is the fastest way to tell if ketones are rising. It is also the best method for parents to quickly decipher whether a child’s illness arises from ketoacidosis or something else.

Remember that urine ketones will always lag behind blood ketone levels. Measuring ketones in the blood detects DKA two to four hours earlier than urine testing. Blood tests allow small changes in ketone levels to be monitored rapidly to determine the effectiveness of therapy. On the other hand, if your urine level has been “high,” and you have taken enough fast insulin to bring the blood sugar down toward normal, you should feel better. However, your urine ketone level may still read “high.” It may take 8 to 24 hours for the ketones to clear from the urine.

Anyone who has had more than one episode of ketoacidosis should test ketones in the blood. Ketoacidosis can be debilitating, expensive, and frightening. It should always be avoided or treated quickly.

Suppose a moderate or large amount of ketones are detected on the test strip. In that case, ketoacidosis is present and immediate treatment is required. If a small level is seen, repeat the test in another hour or two to ensure the level is not rising. See How To Treat Ketoacidosis below.

During any illness, especially when it is severe or prolonged, and any time the stomach becomes upset, ketone levels should be tested every 4 hours. Never assume an upset stomach is due to food poisoning, or your flu-like symptoms are just the flu.

How To Treat Ketoacidosis

The keys to treating ketoacidosis are a) preventing dehydration and b) taking insulin.

If you’re on an insulin pump, scroll down further or click here [link to Treating Ketoacidosis on a Pump, below] for more pump-specific treatment steps.

  • Immediately drink a large amount of non-caloric or low-caloric fluid. Continue to drink 8 to 12 oz. every 30 minutes. Diluted Gatorade, water with a pinch of Nu-Salt™, and similar fluids are useful because they help restore potassium lost because of high blood sugars.
  • Take larger-than-normal correction boluses every 3 hours until the blood sugar is below 200 mg/dl (11 mmol), and ketones are negative. It will take much more than your usual doses of rapid-acting to bring blood sugars down when ketones are present. When ketones are present, 1.5 to 2 times the standard insulin doses may be required. Doses higher than that might be needed if there is an infection or other significant stress.
  • If nausea becomes severe or lasts 4 hours or more, call your physician.
  • If vomiting starts or you can no longer drink fluids, have a friend or family member call your physician immediately. Go directly to an emergency room for treatment.
  • Never omit your insulin, even if you cannot eat. A reduced insulin dose might be needed, but only if your blood sugar is currently low.

Preventing Dehydration

When ketoacidosis happens, it’s critical to drink lots of fluid to prevent or reverse dehydration. The dehydration is caused by excess urination and is quickly worsened if vomiting starts. The start of vomiting requires immediate attention at an ER or hospital where IV fluid replacement can begin.

Taking Insulin

To correct ketoacidosis, it helps to know how far your Blood Sugar Drops on each unit of Humalog, Novolog, or Regular insulin. This Correction Factor or ISF lets you know how much extra insulin to give. If a ketone test shows moderate or large amounts of ketones, much larger doses of insulin than usual may be needed, often 1.5 to 2 times the usual doses. Check blood sugar hourly or monitor your CGM until control has been regained.

Treating Ketoacidosis on a Pump

Insulin pump users may get ketoacidosis earlier than those on MDI because insulin pumps only use short-acting insulin. Because there is no long-acting insulin onboard. Ketosis can begin 3 to 6 hours after an infusion set or patch pump leaks, clogs, detachments, or failures. See the pump troubleshooting information below. If you have ketones, call your doctor and begin treatment.

17.3 Steps to Treat Ketoacidosis on a Pump
If Blood Ketones are less than 1.2 mmol/L
-OR-
Urine Ketones are normal or small:
If Blood Ketones are 1.2 – 3.0 mmol/L
-OR-
Urine Ketones are moderate or large:
  • Give a correction bolus with the pump.
  • Drink 8 to 12 ounces of water or non-caloric fluid every 30-60 minutes
  • Check glucose every 2 hours while above 250 mg/dL (13.9 mmol/L)
  • After 2 hours, if the glucose has not fallen and ketones remain elevated, change the infusion set and site, and jump to the procedure for moderate or large ketones.
  • If the glucose is the same or lower, recheck in 1-2 hours and enter this reading into your pump to see if another correction bolus is needed.
  • If your glucose reading stays high or ketones remain moderate or large, call your physician and follow procedures for moderate or large ketones.
  • Stay hydrated. Start with 16 ounces and drink 8-12 ounces more of water or non-caloric fluid every 30 minutes until control is regained, even if you don’t feel thirsty.
  • Give insulin by injection from Table 17.6 until your glucose is under 200 mg/dL (11.1 mmol/L). Note: More insulin will be needed with ketones if basal insulin has been missed, or you have an illness or fever.
  • Replace the pump insulin cartridge and entire infusion set at a new site, using a new insulin bottle. Check your pump settings.
  • Call your doctor if glucose reading is over 250 mg/dL (14 mmol/L) with moderate or large ketones.
  • If vomiting begins when ketones are large, immediately call your doctor or go to the ER for IV hydration and treatment. Medical treatment is required. Call 911 if no one is available to drive you.
  • Once the glucose is less than 200 mg/dL (11.1 mmol/L), drink fluids with carbs, like Gatorade to speed up the fall in ketones without going low.
Adapted from Pumping Insulin, 6th Edition
17.6 Approximate Correction Insulin Requirements Based on Blood Ketone Levels (Illness or DKA)
Blood Ketone
Level
What It MeansBG = 100-180 mg/dL
(5.5-10.0 mmol/L)
BG = 180-250 mg/dL
(10.0-14.0 mmol/L) 
BG = 250-400 mg/dL
(14.0-22 mmol/L) 
BG > 400 mg/dL
(> 22 mmol/L) 
0.5 mmol/L  or lessNormal ketones Give usual correction bolus from pump.Extra fluid. Give usual correction bolus from pump.  Extra fluid. Give usual correction bolus from pump.  Extra fluid. Give usual correction bolus from pump.  
0.6 to 1.5
mmol/L
Ketones are building up. Check infusion set and pump. Extra carbs and fluid. Give usual bolus doses if infusion set is OK. Recheck in 2-3 hours. Extra carbs and fluid. Inject extra 5% of  TDD* or 1 u for every 80 lbs (40 kgs). Recheck in 2-3 hours. Extra fluid. Give extra 10% of  TDD* or 1 u for every 40 lbs (20 kgs). Recheck in 2-3 hours.  Extra fluid. Give extra 15% of  TDD* or 1 u for every 25 lbs (12 kgs). Recheck in 2-3 hours.  
1.5 to 2.9
mmol/L
Ketoacidosis (DKA) is developing – contact doctor. Check pump, replace infusion set & reservoir. Extra carbs and fluid. Inject extra 5% of  TDD* or 1 u for every 80 lbs (40 kgs). Recheck in 2-3 hours. Extra carbs and fluid. Inject extra 10% of  TDD* or 1 u for every 40 lbs (20 kgs). Recheck in 2-3 hours. Extra fluid. Inject extra 15% of  TDD* or 1 u for every 25 lbs (12 kgs). Extra fluid. Inject extra 20% of  TDD* or 1 u for every 20 lbs (10 kgs). 
At about
3 mmol/L
Severe DKA – call doctor or have someone take you to ER, esp. if vomiting starts. Check pump, replace infusion set & reservoir. Extra carbs and fluid. Inject extra 5% of  TDD* or 1 u for every 80 lbs (40 kgs). Repeat every 2-3 hours based on glucose at that time until ketones come down. Extra carbs and fluid. Inject extra 15% of  TDD* or 1 u for every 25 lbs (12 kgs). Repeat every 2-3 hours until ketones come down. Extra fluid. Inject 20% of  TDD* or 1 u for every 20 lbs (10 kgs). Repeat every 2-3 hours until ketones come down. Extra fluid. Inject 25% of  TDD* or 1 u for every 15 lbs (7 kgs). Repeat every 2-3 hours until ketones come down. 
The doses above are correction bolus or injection doses only. Larger or smaller doses may be needed. 

Basal or long-acting insulin must also be given! Do not stop basal delivery even if you are not eating. 

Do not go to sleep if you are alone and ketones are 1.5 mmol/L or higher. Call someone to stay with you. 

Check your glucose and ketones every 2 hours if your last glucose is above 300 mg/dL (16.7 mmol/L). Above 150 mg/dL in pregnancy. 

Modified from International Society for Pediatric and Adolescent Diabetes recommendations 149 

Pump Troubleshooting

Suppose you’re on a pump and are prone to DKA, or absolutely need to prevent DKA because of pregnancy or a heart condition. In that case, you may want to consider adding a security blanket by taking an injection of long-acting insulin to replace some or all of the basal delivery provided by your pump.

When glucose is unexpectedly high, a correction bolus should start to lower the reading within 2 to 2.5 hours. If this doesn’t happen, suspect an infusion set or pump problem.

Inject insulin with a syringe before troubleshooting the problem. 

If you suspect a pump delivery problem is causing your high blood sugar, troubleshoot by:

  • Remove the set and inspect the infusion site, line, hub, and pump for any problem source.
  • Replace the infusion set, reservoir, and use a new vial if you doubt your insulin. Always anchor your infusion set with tape to prevent problems caused by leaks or full or partial detachment.
  • Once you’ve changed your reservoir and infusion set, deliver a correction bolus that includes enough insulin to also replace the last 4 hours of insulin delivery. (multiply your hourly basal rate by 4. If on an AID, use your average hourly rate). Then set the alarm to check your glucose in 2 hours and correct with insulin every 2 hours until glucose is below 200.
  • As soon as the glucose falls below 200, eat or drink 20-30 grams of carbs and cover them with insulin. This brings blood ketone levels (if present) down more quickly.