Diabetic Ketoacidosis

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Pickering 1 Leticia Pickering Nutrition 302 Dr. Michael Zemel 7 March 2008 Ketoacidosis in the Type I Diabetic Patient Type I diabetes, or insulin-dependent diabetes, is a disease that causes many complications in various systems throughout the body. One of these is diabetic ketoacidosis (DKA), a condition caused by the build up of toxic ketone bodies as a result of impaired disposal mechanisms (1). This disease is characterized by high blood glucose, dry mouth, excessive thirst, and a sweet, fr
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  Pickering 1Leticia Pickering Nutrition 302Dr. Michael Zemel7 March 2008Ketoacidosis in the Type I Diabetic PatientType I diabetes, or insulin-dependent diabetes, is a disease that causes manycomplications in various systems throughout the body. One of these is diabeticketoacidosis (DKA), a condition caused by the build up of toxic ketone bodies as a resultof impaired disposal mechanisms (1). This disease is characterized by high bloodglucose, dry mouth, excessive thirst, and a sweet, fruity smell on the breath, a symptomindicative of the presence of ketone bodies (2). There are many factors that cause diabeticketoacidosis in the type I diabetic patient, but four causes stand out as the most prevalent:insulin deficiency, stress hormone excess, fasting, and dehydration (1). Prevention andtreatments of this toxic condition have become increasingly more effective and accessiblein the past couple of decades. Once thought to be a death sentence, diabetic ketoacidosisis now more easily recognized and treated before significant damage can be sustained.Once thought to be the main cause of diabetic ketoacidosis, the increasedavailability of supplemental insulin, along with increased awareness of other contributingfactors has lowered this assumption (1). In the context of ketoacidosis, relative insulindeficiency is defined as “a plasma insulin concentration between 6 uU/ml and 50 uU/mlwhen the plasma glucose concentration exceeds 250 mg/dl” (1). A lack of insulin inhyperglycemic conditions leads to reduced capability of the body to effectivelymetabolize lipids, leading to the formation of toxic ketone bodies. Although the body is  Pickering 2equipped with mechanisms known as organic alkalis to remove toxins from the body, anexcess of toxins surpasses their ability to neutralize the acidic environment, allowing theketones to accumulate in the blood stream (2). Poor insulin compensation is usually dueto a lack of education and general ignorance as to the serious consequences it may have.For this reason DKA is most often observed in children and newly diagnosed adults wholack the experience to recognize the characteristic symptoms. Another area of diabetesmanagement that is often difficult to master and which can also influence thedevelopment of ketoacidosis is consistency of the diet.Hypoglycemia, or low blood glucose levels, can negatively effect the progressionof ketoacidosis. A properly balanced diet consisting of an appropriate fat to carbohydrateratio utilizes approximately one unit of fat to every two units of carbohydrates. Deviationfrom this balance will interfere with lipolysis, the decomposition of fat molecules. “Whensufficient glucose is not being burned there is excessive and abnormal oxidation of fat,and instead of carbonic acid there is a production of toxic ketone substances” (4). Fasting,used in the context of DKA to describe an inconsistent eating pattern in a diabetic patient,is often secondary reaction to the “nausea, vomiting, and abdominal pain whichaccompany the ketoacidotic state” (1). Another dietary matter that is an integral part of the development of DKA is that of dehydration.Dehydration, much like fasting and hypoglycemia, is often a secondary reactionto the development of DKA as a result of nausea, vomiting and diarrhea. It is easy torecognize dehydration by observation of unusually dry mucous membranes, dry skin, lossof firmness in the skin and elevated heart rate (1). Dehydration and a general deficiencyof fluid in the system only serve to exacerbate the condition as a lack of fluid in the body  Pickering 3 prevents the renal system, namely the kidneys, from functioning properly, whichconsequently leads to an inefficient “excretion of large quantities of glucose and ketone bodies” (4). Water allows important bodily functions to be carried out and so rehydrationmust be a priority in treatment. The condition can be difficult to treat becauseketoacidotic patients usually experience extreme nausea, vomiting and diarrhea whichdecrease their tolerance of the food and beverages that would normally help to restoreappropriate fluid levels. For this reason, immediate hospitalization is required so thatemergency intravenous fluids can be administered. The cause of dehydration, along withinsulin deficiency and hypoglycemia can be explained by a common factor: an excess of stress hormones.Stress, whether it srcinates from internal or external sources is a large factor inthe development of diabetic ketoacidosis. Although the other causes are serious, theyrarely occur independently of an excess of stress hormones. As more research is done inthe field of ketoacidosis, it is increasingly well established that there is a positivecorrelation between its development and stress hormone secretion. One study found thatafter a stimulus, the fever inducing drug pyrogen, was purposefully administered on a testsubject to determine the effects of stress on the development of ketoacidosis, surprisingresults were observed. The stress hormone groups, including catecholamines, cortisol,growth hormone, and glucagon, were all secreted in response to the internal stresscausing an increase in plasma glucose and ketone bodies. Despite frequent insulininjections in an attempt to stabilize those levels, they maintained high levels whichindicated the role that stress hormone secretion played in initiating ketoacidosis (1). Thisobservation makes sense, especially considering the role that glucagon has in regulating  Pickering 4the concentration of ketone bodies. Glucagon is primarily responsible for regulating the production of glucose through a process called gluconeogenesis and for regulating therate of lipolysis. An increase in glucagon, such as occurs when a stress is introduced tothe body, results in an increase in the rate of lipolysis. This increase in lipiddecomposition “leads to a higher concentration of free fatty acids which leads to higher ketone concentration” (5).Effective treatment of diabetic ketoacidosis is a multi step process that requiresthe expertise of specialized medical professionals. The first issue that must be treated isdehydration. This takes priority because once fluid and electrolyte balance is restored the body will have the water that is essential for its metabolic processes. Rapid volumeexpansion is followed by a period of slow volume expansion to reduce the occurrence of cerebral edema, or swelling of the brain (3). As previously mentioned, many patientssuffering dehydration as a side effect of ketoacidosis also experience nausea, vomitingand diarrhea. These patients should have their fluids administered intravenously toimprove absorption rates. Although the first priority in treatment is to restore fluid balance to the patient, the other causes of DKA must also be addressed before a fullrecovery can be made.One method of insulin control is an experimental treatment known as DiabetesTreatment and Teaching Programs (DTTPs). This method’s effectiveness was tested inlaboratory research experiment that was recently published in Diabetes Care. DTTP is a program that focuses on education on proper insulin dosage and administration to control blood glucose levels. Subjects were individuals with type I diabetes who experienced atleast three occurrences of ketoacidosis over the course of a year, which qualified them as
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