MMM, SMELLS FRUITY! Diabetes Case Study
Let’s review the basics.
People who have diabetes, in particular type 1 diabetes are at risk of suffering a keto (keto being short for diabetic ketoacidosis or DKA). If you ever suspect someone is having a keto it’s important to take prompt and immediate action. DKA is a life-threatening problem. It usually happens because the body doesn’t have enough insulin. Cells can’t use the sugar in the blood for energy, so they use fat for fuel instead. Burning fat makes acids called ketones and, if this process goes on for a while, the build up of ketones causes the blood to become acidic. When ketones are produced too quickly and build up in the blood and urine, they can be toxic and lead to severe complications like cerebral oedema, heart attack and kidney failure.
Why does this happen?
It can be the first sign that someone has type 1 diabetes who have not yet been diagnosed. It can occur in someone who has already been diagnosed with type 1 diabetes when they suffer an infection, injury, a serious illness, surgery or just missing doses of insulin.
People with type 2 diabetes can also develop DKA, usually triggered by prolonged uncontrolled blood sugar, missing doses of medicine or severe illness or infection but is less common and less severe.
What are the symptoms?
Common symptoms of DKA can include:
- decreased alertness
- deep, rapid breathing
- dry skin and mouth
- flushed face
- frequent urination or thirst that lasts for a day or more
- fruity smelling breath
- muscle stiffness or aches
- nausea and vomiting
- stomach pain
Exams and tests
Anyone who is already diagnosed with type 1 diabetes will be taught to check their urine as well as their blood sugar. A diabetic patient will throw ketones into their urine and can be a great way for early detection for ketoacidosis. If the patient suspects they may be becoming acidotic or if you suspected, like you did with Mr Jones, that your patient was experiencing the symptoms commonly seen in a DKA most often, urine testing is done first. If the fringe is positive for ketones, most often beta-hydroxybutyrate is measured in the blood. This is the most common ketone measure. The other main ketone is acetoacetate.
Some of the other tests that may be performed include arterial blood gas, metabolic panel (a group of blood tests that measure your sodium, potassium, kidney function, liver function and other electrolytes including the anion gap), blood glucose, blood pressure and osmolality of urine and blood.
The goal of treatment is to correct the imbalance and bring the blood sugar down to within normal parameters with insulin. Often a patient is very dry so IV fluids are administered to restore fluids lost through urination, loss of appetite, and vomiting is essential. IV fluids may well have titrated levels of sodium, potassium and/or chloride added to correct the electrolye imbalances. Most people will respond to treatment within 24 hours. Sometimes it can take longer but if left untreated, it can lead to severe illness or death.
Careful monitoring is required throughout treatment to avoid any complications. Insulin allows sugar to enter the cells again but will cause the blood sugar level to drop. If the blood sugar level drops too quickly, the patient can experience low blood sugar (hypoglycaemia).
The fluids and insulin used to treat DKA can cause the potassium level to drop too low. A low potassium level can impair activities of the heart, muscles and nerves. Adjusting the blood sugar level too quickly can produce swelling in the brain. This complication appears to be more common in paediatric patients, especially those with newly diagnosed diabetes.
Even if you don't have diabetes, it's a good idea to learn and recognise the signs and symptoms and know when to test for ketones. For example, if your patient becomes sick check if their diet has changed or have they missed a dose of medication. Make sure they understand healthy eating and physical activity should be part of your their routine together with taking oral medications and insulin as directed. Regular blood sugar monitoring is vital, especially in the early stages until they get to know how their body responds to different foods and varying levels of activity. They may need to check your blood sugar three or four times a day - more often if they are ill or under stress.
Their doctor or diabetes educator will teach them a sliding scale so they how much insulin to give based on each blood sugar level result. They will also be given a personalised diabetic treatment plan to bring their blood sugar level to their target range. They may also be required to test their urine for excess ketones. If the ketones test kit indicates moderate or high ketones, they should contact their doctor straight away and seek emergency care.
If they use an insulin pump, check the insulin is flowing through the tubing and not blocked, or kinked or disconnected from the pump.
Maloney GE, Glauser JM. Diabetes mellitus and disorders of glucose homeostasis. In: Walls RM, Hockberger RS, Gausche-Hill M, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 9th ed. Philadelphia, PA: Elsevier; 2018:chap 118
Pasquel FJ, Umpierrez GE. Hyperglycemic crises: diabetic ketoacidosis and hyperglycemic hyperosmolar state. In: Jameson JL, De Groot LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric. 7th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 46.
As you walk into your patients room you notice Mr Jones is pretty drowsy and didnÕt really respond to your greeting. His breathing is deep and rapid, mouth looks dry and his face is flushed. He has his hands over his stomach like he has a stomach ache and he is frowning like heÕs in pain. YouÕre understandably concerned so approach his bed. As you lean in to speak to Mr Jones to see if he responds you can smell a fruity sweetness in his breath É. Now that should give it away. What do you think is happening to Mr Jones? If you suspect that he may be in a state of diabetic ketoacidosis then you are possibly correct. Great deducing Sister!