I’ve read about people going to the Hospital with DKA, for not having any insulin injections (like myself but I was misdiagnosed type 2 then…)
but many of those people say they do had their injections and still got into DKA. including adults and children. (I cannot imagine what parents could do that on purpose to their own children… but thats another topic)
Could somebody please educate me on what could possibly put somebody on DKA despite having all the necessary precautions?? (exercise, hydration, insulin etc)
I’m not the one who can give you the science behind it, but my first idea has to do with the amount of detail behind the claims… How much insulin? How recently? I guess I would be interested in hearing a detailed account before attempting an answer. That’s the devil’s advocate in me, but I think diabetics are making a lot of mistakes that they incorrectly put down as a problem with their disease rather than as a problem in their management. And I’m not judging… I did just that for years. It was my best trick.
Well, suppose you are recently diagnosed with Type 1, and your doctor did some arithmetic based on your weight, and instructed you to take 10u of Lantus every evening and 1u insulin for every 20g carb you eat. But your body actually needs 20u of basal and 1u for every 7g carb. And then you go eat a half a pecan pie and your best guess is that you need 15u insulin. If you are not measuring your BG regularly, I can imagine that you’d find yourself very thirsty a while later, and with a BG of 700 you could go into DKA overnight. So it could be a consequence of ignorance and inattention.
I know I came close, when first using insulin pump. I didn’t realize the infusion site was bad, but still gave boluses. But BG kept going up, and I was feeling nauseous thought maybe getting flu… I was on business trip, staying in hotel, eating foods I wasn’t sure of carbs so probably also under bolused.
Called my endo, who quickly told me to inject by syringe, and drink lots of fluids. I was probably close to ending up in ER, but caught it just in time. I recall being nervous to take insulin by syringe, because pump showed quite a bit of active insulin. Problem was, it really wasn’t getting into my system via pump.
It would always be a case where people don’t inject enough.
When my son gets sick, for instance, his need for basal insulin can double, and it is exceedingly difficult to bring his highs down. If we did not have a CGM we would have to test him at least every hour. When we use modern insulin, it is not unusual for us to treat him with large quantities of rapid insulin every hour to hour and a half, for 4-5 days on a row.
Because we are afraid he might throw up later (therefore not be able to take carbs) we are very careful about increasing basal too much while on MDI (i.e. not on a pump), so we typically end up not increasing his basal as much as we’d like, which causes even more rapid insulin injections.
In this situation, particularly if you don’t test very often, it could be easy to get into DKA, I think, in particular for people who are not very experienced, who are not accustomed to testing often, or who don’t have anyone helping them if they are very sick. Not having someone competent to help if you are very sick may be a real issue: when you are sleeping 18 hours a day with no CGM it would be easy not to treat properly.
In these situations, testing for ketones is very important, btw.
I went into DKA when I had salmonella when I was 18. I was told I almost died from it. I don’t remember the details super well (was almost 20 years ago), but I was taking insulin, but not enough to suppress highs (I think I was running 200s, maybe some 300s), but I think if anything, the error was we backed off insulin a little, rather than increasing it dramatically (which I likely needed, a la sick day rules), because I also couldn’t keep food down. We were also traveling abroad at the time, so the plan was to manage until we got home—was the worst flight imaginable, and that night before I could get into the doctor the next day, I felt like I couldn’t breathe and went to the ER in severe DKA extremely dehydrated. My mom was told I was probably 24 hours away from potentially permanent organ damage or worse, and I still have minor damage to one of my radial arteries from their taking a blood gas from my super dehydrated arm. I was in the ICU for about a week, and it was about a month recovery at home before I was back to normal.
I was not testing ketones at the time—I admittedly fell out of practice and still pretty much never do because even at high blood sugars I almost never produce any, but now I know to have the proper level of fear of stomach bugs and the havoc they can wreak. These days, if I couldn’t keep food down for over a day or so, I’d first try the emergency Zofran I now keep a stash of in my house, and then I’d likely go to the hospital way sooner for IV hydration, glucose (in order to be able to take lots of insulin), and, if needed, IV insulin, before letting things get out of hand.
Starting in my 20s I used to get sick with norovirus every December like clockwork and end up in DKA. The first few years I was on my first pump and I don’t think anyone ever taught me about increasing insulin when I was sick. That went on for about 20 years. In the beginning I’d be sick at home for days and seriously dehydrated before I went to hospital for IV saline/glucose and heavy-duty anti-emetics, but later on I’d check in at the first signs. It was so regular, one year I must have shown up later than usual because one of the nurses said “I thought you’d left town.” And then it just stopped and it’s never happened since.
I remember reading a physician’s warning that with BG over 300 and dehydration, acute kidney failure can happen in less than 24 hours. So if you can’t keep well hydrated, go get IV fluids before things get serious.
When my son was diagnosed, he was in DKA. He was turned down by the local ER because they felt they lacked the skills: they sent him to a special ER at the regional Children’s hospital, which has a reputation for having a very good DKA procedure. I was told that getting someone out of DKA takes strong team skills and is a risky process, which is why they were TURFing DKA patients.
It’s definitely complex and prone to complications—I was mostly out of it for days (I was at the point where they estimated about 10 liters of water loss). Your electrolytes get completely out of balance, and I had, among other things, potassium in my IV, which then infiltrated (IVs are all the more challenging on dehydrated people), and potassium is super caustic if it seeps into tissue instead of being diluted into the blood stream. Because I was so out of it, I was in pain but couldn’t communicate it very effectively, so it took a while to get it corrected, and I essentially was burned, from the inside, on my wrist, which then got a staph infection (so easy to get in hospitals) and sensory nerve damage (the side of my hand into my thumb was initially entirely numb to the touch) that took many months to heal painfully. I eventually recovered almost all of the sensation, but it was an awful process. Still have what look like small burn scars on that wrist.
This all happened at a nationally acclaimed hospital, so my strongest advice is to be very prepared with both knowledge and supplies (e.g., zofran—ask for a script to fill and keep for emergencies) to deal with food poisoning/norovirus/etc and to get treatment early if it’s not easily manageable, since once you’re in the state I was in, no matter where you get treatment, it’s easy for things to go wrong. I get my flu shot every year, but it’s the stomach bugs that I think are by far the most worrisome for diabetics and which I wish I could vaccinate against. I try to steer super clear of anyone who might have it if at all possible and wash my hands super carefully, because hand sanitizer doesn’t kill norovirus (the only disinfectant that kills it is bleach).
Your story is definitely the worse DKA story I have read I can’t help feeling so bad for the very young woman you were.
Your story and @Beacher’s right above are giving me a healthy respect for norovirus, and will cause me to review our prophylactics. We focus a lot on hand hygiene, but we also believe in the hygiene hypothesis, so we consider it is not totally good to have an aseptic house Now this thread is making me think through how you can balance both.
Thanks. It was awful for me, but it was even worse for my mom—she told me years later when she called 911 that night, she thought I was dying, and I think she blamed herself so much for not preventing it from getting that bad (she was trying hard to get me back home though before getting treatment, which in retrospect was obviously an error). I actually think she had some degree of secondhand PTSD from the event that took years to recover from. And mine was salmonella, not norovirus (but I am very careful re: anything that causes prolonged vomiting), so even though it was acquired from a restaurant, she became fanatic about food cleanliness ever since. I’m also really careful with raw chicken in particular.
I’m not super convinced on the hygiene hypothesis, but even if I were I’d still think things like good hand-washing during bathroom and food prep is probably beneficial – you just need to get some cows or sheep nearby that you interact with in between. And for Kaelen it may not make much difference ata this point.
There are some interesting studies in Hutterites vs. Mennonites – genetically similar farming groups that have very different rates of allergies and asthma. The difference is that one group has kids interact with the farm animals when very young, while the other group only introduces the children to animal husbandry later in life. That group has very high rates of allergies and asthma, while the ones who expose their kids young have lower rates than average.
The Canadian Pediatric Society today announced it has revised its earlier recommendation to not feed high-risk infants common allergens (peanuts, eggs, cow’s milk, shellfish, etc.) for the first six months, based on growing evidence that earlier introduction of these allergens can prevent food allergies.
Just had this happen last week. Ended up in DKA due to dehydration. They think it was an infection that pushed me over the edge. I possibly was already dehydrated from yard work and being out in the sun all day long. That night i became ill and couldn’t keep fluids down. Not sure if this was from DZkA or infection. Then my ketones showed very high. I headed to the ER for iv fluids. My blood was very acidic, potassium was high, white blood cells were very high. Kidneys weren’t happy. Resting heart rate was 117, respirations were 36 per minute. Veins were barely there so blood gases and iv very difficult. Obviously waited longer than i should have to seek treatment, it was kind of the perfect storm.
I am T1D on the 670g autopump and take invokana due to insulin resistance. The invokana makes you dehydrated so fluid intake is important. Working outside that day made me more dehydrated than normal. The doctor thinks my autopump was managing my bgs so well that i never really had excessively high bgs which would have alerted me to check ketones sooner. They officially diagnosed me with sepsis.
The take away from this experience is that with ever changing and better treatment options things like DKA can really sneak up on you fast. With the auto pump my control is good.
My doctor has taken me off of invokana for the time, it was a godsend to me while i was very insulin resistant but thankfully I don’t have as much trouble with that now that i am “older” and hormones have chilled out.
Keep those ketone strips handy and use them. They are cheap and easy to use.