Diabetic ketoacidosis (DKA) DKA occurs most often in patients with type 1 diabetes and/or those less than 65 years of age, although it can occur with type 2 diabetes as well. DKA is an acute complication of hyperglycemic crisis. DKA is precipitated by acute insulin deficiency. Such deficiency can be caused by illness; stress; infection; and, in insulin-dependent patients, failure to take insulin (Ignatavicius et al., 2018; Mayo Clinic, 2020b; Rebar et al., 2019). Without adequate amounts of insulin, which allow the cells to take in glucose to convert it to energy, glucose accumulates in the blood. The body begins to break down fat as an alternative fuel. When this happens, toxic acids known as ketones build up in the blood. Without treatment, DKA can result in coma or death (Ignatavicius et al, 2018; Mayo Clinic, 2020b). The signs and symptoms of DKA usually develop rapidly, often within 24 hours. Patients experience polyuria, polydipsia, nausea, vomiting, abdominal pain, weakness or unusual fatigue, shortness of breath, fruity-scented breath, and confusion. Blood testing shows hyperglycemia and high levels of ketones in the urine (Mayo Clinic, 2020b; Rebar et al., 2019). Because untreated DKA can be fatal, patients experiencing the signs and symptoms should seek emergency medical help. Emergency treatment usually includes insulin therapy, electrolyte replacement because inadequate amounts of insulin can reduce various electrolyte levels, and fluid replacement to correct dehydration (Mayo Clinic, 2020b). Risk factors for DKA include having type 1 diabetes and frequently missing insulin doses. (Mayo Clinic, 2018g). Until recently, it was believed that if diabetes occurred in childhood, it was type 1 diabetes. Now it is known that children also develop type 2 diabetes. As obesity in children increases, so does the incidence of type 2 diabetes in that population (Dansinger, 2021a). Therefore, it is important to identify risk factors and work with patients of all ages to reduce the risk of developing type 2 diabetes. It is also important to be alert to the clinical manifestations of the disease realizing that it can affect all age groups. It can take years for the signs and symptoms of type 2 diabetes to become evident. Following are clinical manifestations of untreated diabetes (Ignatavicius et al., 2021; Mayo Clinic, 2021g): ● Polyuria and polydipsia: Excessive buildup of glucose in the blood stream causes fluid to move from the cells into the bloodstream to maintain homeostasis. This increases thirst and fluid intake casing an increase in dilute urine production. ● Polyphagia: When cells fail to receive adequate amounts of glucose for energy production, muscles, and organs experience energy depletion. This triggers intense hunger as the body attempts to obtain nourishment and energy. ● Weight loss: Even though patients may be eating more because of intense hunger, weight loss can occur. This is because the body is using alternative fuel sources in muscle and fat because it cannot metabolize glucose. Calories are lost as glucose is excreted in urine. ● Blurred vision: As glucose levels increase in the blood stream, fluid may be pulled from the lenses of the eyes to restore homeostasis. This can interfere with the ability of the eyes to focus, thus causing blurred vision. ● Fatigue: When cells are deprived of glucose and the ability to create energy, weakness, fatigue, and irritability can occur. ● Slow-healing cuts, lacerations or wounds, or frequent infections: Type 2 diabetes interferes with the body’s ability to heal and to resist infections. Diabetes may be diagnosed based on plasma glucose criteria, either the fasting plasma glucose (FPG) value or the 2-hour plasma glucose (2-hour PG) value during a 75-g oral glucose tolerance test (OGTT), or A1C criteria (ADA, 2021b).
Persons with diabetes mellitus, especially those with type 1 diabetes, should work with their health care providers to manage conditions that trigger DKA. Following are examples of such conditions (Mayo Clinic, 2020b): ● Infections and illnesses: Infections and illnesses can cause the body to produce higher levels of adrenaline or cortisol, both of which are antagonistic to insulin. Common conditions that trigger DKA are pneumonia and urinary tract infections. ● Inadequate insulin therapy: Missing insulin treatments or taking inadequate amounts of insulin can trigger DKA. ● Miscellaneous problems: High fever, surgery, physical or emotional trauma, or alcohol or drug abuse, especially cocaine, can trigger DKA. Healthcare Professional Consideration: It is imperative that healthcare professionals assess the knowledge of patients and families regarding the signs and symptoms of DKA, what causes it, and what to do about it. Parents may want to discuss the symptoms of DKA with their diabetic child’s teachers, especially if the child participates in sports. Self-Assessment Quiz Question #5 A patient is at risk for developing DKA if which of the following problems exist: a. Excessive insulin. ● Areas of darkened skin: Areas of darkened skin, called acanthosis nigricans, are dark velvety patches of skin in the folds and creases of the body. They are usually noted in the neck and axilla. Healthcare Professional Consideration: Thirst mechanisms function less efficiently in elderly persons. So older adults may not report polydipsia when relaying signs and symptoms (Ignatavicius et al., 2018). Diabetic hyperglycemic hyperosmolar syndrome (HHS) is a complication of type 2 diabetes. HHS is characterized by extremely high blood glucose levels without the presence of ketones, extreme dehydration, and decreased levels of consciousness. The kidneys attempt to rid the body of excess amounts of glucose in the blood by increasing urinary output. Without adequate fluid replacement, dehydration occurs. Additionally, dehydration makes the blood more concentrated with sodium, glucose, and other substances. This condition is known as hyperosmolarity and causes the body to withdraw fluid from other body organs (including the brain) to restore balance. Electrolyte balances are disturbed as well. If blood glucose levels are not returned to normal, an ongoing cycle of hyperglycemia and dehydration occurs that can lead to coma and even death (Ignatavicius et al. 2018; MedlinePlus, 2021a). The goals of treatment are to correct dehydration, restore fluid and electrolyte balance, and control blood glucose levels. Intravenous fluids containing appropriate amounts of various electrolytes are administered as well as insulin via the venous route. Untreated, HHS may lead to shock, thrombosis formation, cerebral edema, and lactic acidosis (Ignatavicius, Workman, & Rebar, 2018; MedlinePlus, 2021a).
b. Hypothermia. c. Prediabetes. d. Urinary tract infection. CLINICAL MANIFESTATIONS OF TYPE 2 DIABETES MELLITUS
DIAGNOSIS OF DIABETES MELLITUS
The ADA (2021b) diagnostic criteria include: ● A fasting plasma glucose (FPG) level >126 ng.dL (7.0 mmol/L), or ● A 2-hour plasma glucose level >200 mg/dL (11.1 mmol/L) during a 75-g oral glucose tolerance test (OGTT) or
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