Ketoacidotic coma, also known as diabetic ketoacidosis (DKA), is a serious complication that occurs in people with diabetes when the body produces high levels of blood acids called ketones. It develops when the body cannot produce enough insulin to allow blood sugar to enter cells, causing the body to break down fat for energy and produce a buildup of ketones. Symptoms include thirst, frequent urination, nausea, vomiting, and confusion. Treatment involves fluid replacement, electrolyte replacement, and insulin therapy to lower blood sugar and acid levels. DKA requires emergency treatment in a hospital to prevent complications like low blood sugar, low potassium, and swelling of the brain.

1. KETOACIDOSIS / KETOACIDOTIC
COMA
Dr.Gurudev
MBBS

2. Ketoacidotic coma
 Definition –
 * it is a serious complication of diabetes that occurs when your body produces high levels of blood
acids called ketones.
 * The condition develops when your body can't produce enough insulin. Insulin normally plays a
key role in helping sugar (glucose) — a major source of energy for your muscles and other tissues
— enter your cells. Without enough insulin, your body begins to break down fat as fuel. This
process produces a buildup of acids in the bloodstream called ketones, eventually leading to
diabetic ketoacidosis if untreated.
 * If you have diabetes or you're at risk of diabetes, learn the warning signs of diabetic ketoacidosis
— and know when to seek emergency care.
 * High levels of ketones can poison the body. When levels get too high, you can develop DKA. DKA
may happen to anyone with diabetes, though it is rare in people with type 2.

3. What are the warning signs ?
 usually develops slowly. But when vomiting occurs, this
life-threatening condition can develop in a few hours. Early
symptoms include the following:
 Thirst or a very dry mouth
 Frequent urination
 High blood glucose (blood sugar) levels
 High levels of ketones in the urine
 Then, other symptoms appear:

4. symptoms
 Constantly feeling tired
 Dry or flushed skin
 Nausea, vomiting, or abdominal pain
(Vomiting can be caused by many illnesses, not just ketoacidosis. If vomiting continues for more than 2 hours,
contact your health care provider.)
 Difficulty breathing
 Fruity odor on breath
 A hard time paying attention, or confusion
 Excessive thirst
 Frequent urination
 Abdominal pain
 Weakness or fatigue
 Fruity-scented breath
 Confusion

5. How do I check for ketones?
 You can detect ketones with a simple urine test using a test strip, similar to a blood testing strip. Ask
your health care provider when and how you should test for ketones. Many experts advise to check
your urine for ketones when your blood glucose is more than 240 mg/dl.
 When you are ill (when you have a cold or the flu, for example), check for ketones every 4 to 6 hours.
And check every 4 to 6 hours when your blood sugar is more than 240 mg/dl.
 Also, check for ketones when you have any symptoms of DKA.

6. What causes DKA?
 Here are three basic reasons for moderate or large amounts of ketones:
 Not enough insulin
 Maybe you did not inject enough insulin. Or your body could need more insulin than usual because of
illness.
 Not enough food
 When you're sick, you often don't feel like eating, sometimes resulting in high ketone levels. High levels
may also occur when you miss a meal.
 Insulin reaction (low blood glucose)
 If testing shows high ketone levels in the morning, you may have had an insulin reaction while asleep.

7. Complications
 Diabetic ketoacidosis is treated with fluids, electrolytes — such as sodium, potassium and chloride —
and insulin. Perhaps surprisingly, the most common complications of diabetic ketoacidosis are related
to this lifesaving treatment.
Possible complications of the treatments
 Treatment complications include:
 Low blood sugar (hypoglycemia). Insulin allows sugar to enter your cells, causing your blood sugar
level to drop. If your blood sugar level drops too quickly, you can develop low blood sugar.
 Low potassium (hypokalemia). The fluids and insulin used to treat diabetic ketoacidosis can cause
your potassium level to drop too low. A low potassium level can impair the activities of your heart,
muscles and nerves.
 Swelling in the brain (cerebral edema). Adjusting your blood sugar level too quickly can produce
swelling in your brain. This complication appears to be more common in children, especially those with
newly diagnosed diabetes.
 Left untreated, the risks are much greater. Diabetic ketoacidosis can lead
to loss of consciousness and, eventually, it can be fatal.

8. Prevention
 There's much you can do to prevent diabetic ketoacidosis and other diabetes complications.
 Commit to managing your diabetes. Make healthy eating and physical activity part of your daily
routine. Take oral diabetes medications or insulin as directed.
 Monitor your blood sugar level. You might need to check and record your blood sugar level at least
three to four times a day — more often if you're ill or under stress. Careful monitoring is the only way to
make sure your blood sugar level remains within your target range.
 Adjust your insulin dosage as needed. Talk to your doctor or diabetes educator about how to adjust
your insulin dosage in relation to your blood sugar level, what you eat, how active you are, whether
you're ill and other factors. If your blood sugar level begins to rise, follow your diabetes treatment plan
to return your blood sugar level to your target range.
 Check your ketone level. When you're ill or under stress, test your urine for excess ketones with an
over-the-counter urine ketones test kit. If your ketone level is moderate or high, contact your doctor
right away or seek emergency care. If you have low levels of ketones, you may need to take more
insulin.
 Be prepared to act quickly. If you suspect that you have diabetic ketoacidosis — your blood sugar
level is high, and you have excess ketones in your urine — seek emergency care

9. Diagnosis
 If your doctor suspects diabetic ketoacidosis, he or she will do a physical exam and various blood tests.
In some cases, additional tests may be needed to help determine what triggered the diabetic
ketoacidosis.
 Blood tests
 Blood tests used in the diagnosis of diabetic ketoacidosis will measure:
 Blood sugar level. If there isn't enough insulin in your body to allow sugar to enter your cells, your
blood sugar level will rise (hyperglycemia). As your body breaks down fat and protein for energy, your
blood sugar level will continue to rise.
 Ketone level. When your body breaks down fat and protein for energy, acids known as ketones enter
your bloodstream.
 Blood acidity. If you have excess ketones in your blood, your blood will become acidic (acidosis). This
can alter the normal function of organs throughout your body.

10. Additional tests
 Your doctor may order tests to identify underlying health problems that might have contributed to
diabetic ketoacidosis and to check for complications. Tests might include:
 Blood electrolyte tests
 Urinalysis
 Chest X-ray
 A recording of the electrical activity of the heart (electrocardiogram)

11. Treatment
 If you're diagnosed with diabetic ketoacidosis, you might be treated in the emergency room or
admitted to the hospital. Treatment usually involves:
 Fluid replacement. You'll receive fluids — either by mouth or through a vein (intravenously) — until
you're rehydrated. The fluids will replace those you've lost through excessive urination, as well as help
dilute the excess sugar in your blood.
 Electrolyte replacement. Electrolytes are minerals in your blood that carry an electric charge, such as
sodium, potassium and chloride. The absence of insulin can lower the level of several electrolytes in
your blood. You'll receive electrolytes through a vein to help keep your heart, muscles and nerve cells
functioning normally.
 Insulin therapy. Insulin reverses the processes that cause diabetic ketoacidosis. In addition to fluids and
electrolytes, you'll receive insulin therapy — usually through a vein. When your blood sugar level falls to
about 200 mg/dL (11.1 mmol/L) and your blood is no longer acidic, you may be able to stop
intravenous insulin therapy and resume your normal subcutaneous insulin therapy.

12. REFERENCES
 Ketoacidosis (DKA). American Diabetes Association. http://www.diabetes.org/living-with-
diabetes/complications/ketoacidosis-dka.html. Accessed Aug. 2, 2015.
 Diabetic ketoacidosis (DKA). Merck Manual Professional Version.
http://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/diabetes-
mellitus-and-disorders-of-carbohydrate-metabolism/diabetic-ketoacidosis-dka. Accessed
Aug. 2, 2015.
 Kitabchi AE, et al. Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults:
Clinical features, evaluation and diagnosis. http://www.uptodate.com/home. Accessed Aug. 2,
2015.
 Kitabchi AE, et al. Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults:
Treatment. http://www.uptodate.com/home. Accessed Aug. 2, 2015.
 Jeffries CA, et al. Preventing diabetic ketoacidosis. Pediatric Clinics of North America.
2015;62:857.
 Checking for ketones. American Diabetes Association. http://www.diabetes.org/living-with-
diabetes/treatment-and-care/blood-glucose-control/checking-for-ketones.html. Accessed
Aug. 2, 2015.
 Hirsch IB, et al. Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults:
Treatment. https://www.uptodate.com/contents/search. Accessed May 17, 2018.