Diabetic ketoacidosis natural history, complications and prognosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Natural History

If left untreated, diabetic ketoacidosis may progress to multi-organ failure and death. The ketone bodies (β-hydroxybutyrate and acetoacetate) and ketoacids stimulate chemoreceptors in the CNS, resulting in hyperventilation. Clinically, this response is observed as Kussmaul respirations. Early in the course of the ketoacidotic process, hyperventilation results in a reduction of pCO2. The metabolic acidosis is compensated, and pH may be normal or only slightly reduced (e.g., in mild or moderate DKA). As DKA progresses into the severe stages, more significant acidosis occurs and pH falls. Any compromise in the ability of the lungs to compensate for the acidosis such as might occur in pulmonary disease (pneumonia, asthma, or adult respiratory distress syndrome) or CNS depression (e.g., cerebral edema), would be expected to worsen the acidosis and the prognosis. Other intercurrent conditions, such as sepsis or renal insufficiency, would also be expected to worsen the prognosis. Although acidosis impairs myocardial contractility, heart failure and cardiogenic shock are rare in children with DKA. Heart failure, myocardial infarction, and arrhythmias during DKA are not uncommon in adults. In children, hypotension or shock during DKA is nearly always the result of hypovolemia or cerebral edema.

• Vomiting or nausea
• Shortness of breath or fruity breath
• Decreased consciousness or mental stupor

Complications

People with diabetic ketoacidosis need close and frequent monitoring for complications. Surprisingly, the most common complications of DKA are related to the treatment:

• Hypokalemia and often, potassium depletion
• Cerebral edema
• Hyperglycemia
• Ketoacidemia
• Fluid and electrolyte depletion
• Aspiration
• Unrecognized renal tubular necrosis
• Pulmonary edema

Prognosis

Prognosis of diabetic ketoacidosis depends on:

• Whether the patient is diagnised or treated in time
• The age of the patient: Older people have worse outcomes than the young.
• Whether complications, such as heart attack, renal failure and hypokalemia occur.