On one Monday morning last month, I was doing my usual hospital rounds. I noticed a young man who had just arrived, he was writhing in abdominal pain, breathing so fast and aggressively, he was semi-conscious and his extremities were cold. He also looked severely dehydrated , had a low blood pressure with a rapid heart rate. He also looked like he had a rapid weight loss recently; he was wasted. I quickly stopped all that I was doing and went to him. A nurse, Mr. Ambani, abandoned his 'wound-dressing' duties and quickly followed me. We positioned our patient properly and both of us couldn't help but notice a sweet smell emitting from his mouth (acetone breath due a waste called ketones). He was in a very critical condition. I made a quick working diagnosis of Diabetic Keto-Acidosis (DKA) and asked the nurse to dash and get a glucometer( gadget for measuring blood sugar levels) and resuscitation tray with. I.V branulas and fluids. We were aware that the patient had no history of diabetes but we knew that he could be a new case of the disease . The sugars were unrecordably high ; my diagnosis of Diabetic KetoAcidosis was right . We needed to act in seconds or end up losing the patient . His veins were collapsed so I quickly went for the jugular and was in on the first jab. Meanwhile the nurse had given three shots of insulin and I started giving Fluids intravenously (Normal Saline) as soon as possible. Potassium Chloride and Sodium Bicarbonate was also ready. Another nurse joined us and assisted in putting a urinary catheter and getting a urine sample for the labs. He also helped as we struggled to get another I.V line to keep the fluids running fast. After two hours, the condition was still critical and the sugars were still unrecordably high. We put in a continuous insulin infusion as the fluids ran as we monitored and recorded the sugars every 30 minutes . Still after 4 hours, the sugars were very high but we kept on. His condition was better though not stable. There was a ray of hope soon and the sugars started dropping. The young man's breathing also improved significantly and within hours he was awake and responding to commands. By 10.00pm that evening he was walking around. I ended up not completing my ward rounds because I spent hours on the patient but I was glad that a life had been saved.
This case reminded me of an Autopsy I watched on TV being done by the world renowned pathologist DR.G (Channel 171 Dstv). A Diabetic patient had just collapsed suddenly after a usual day of work. The patient had sensed that she was feeling weak and mistook her situation as a case of low blood sugars so she quickly took a glass of juice, only for her to collapse and die. Her autopsy was unremarkable but he blood analysis confirmed a serious case of Diabetic Keto-Acidosis, a condition caused by high blood sugars. She was strictly adherent to her drugs and diabetic diet so her family could not fathom how the condition could have attacked her. It was later learned that she had travelled a week earlier by bus with her drugs safely carried in her back-pack. The drugs were not stored in the refrigerator as required so their potency was gone. She was injecting herself during the week with insulin that was not working due to high temperatures in the bag and bus hence the high blood sugars .
Diabetic ketoacidosis (DKA) is an acute, major, life-threatening complication of diabetes that mainly occurs in patients with type 1 diabetes, but it is not uncommon in some patients with type 2 diabetes. In layman terms, I tell my patients that Diabetes Type 1 is mainly In those who were diagnosed with Diabetes before the age of ~35years. There usually a total lack or very low production of insulin by the pancreas in this type of Diabetes, hence the need of the patients to be on insulin and not oral drugs.
DKA is a complex disordered metabolic state characterized by high blood sugars, dehydration , ketoacidosis, and ketonuria. ( presence of a metabolic waste called Ketone in the blood and urine).
Signs and symptoms
The most common early symptoms of DKA are the insidious increase in thirst and frequency of urination.
The following are other signs and symptoms of DKA:
Malaise, generalized weakness, and fatigability
Nausea and vomiting; may be associated with diffuse abdominal pain, decreased appetite, and anorexia
Rapid weight loss in patients newly diagnosed with type 1 diabetes.
History of failure to comply with insulin therapy or missed insulin injections due to vomiting or psychological reasons.
Decreased perspiration
Altered consciousness (eg, mild disorientation, confusion); frank coma is uncommon but may occur when the condition is neglected or with severe dehydration/acidosis
Signs and symptoms of DKA associated with possible intercurrent infection are as follows:
Fever
Coughing
Chills
Chest pain
Difficulty in breathing
Joint pains
Patients having these symptoms must rush to hospital for check up and proper management. This is for all people irregardless of whether or not they are diabetic. In the case of my patient above, he was not a known diabetic and this was his first time to be diagnosed).
DKA is a condition that is is deadly but at the same time very easy to treat and reverse if diagnosed on time.
It's sad, but I have heard and witnessed stories of diabetic patients found collapsed and dead in their houses. This year alone I have certified deaths of 2 young diabetic patients who collapsed suddenly after a normal working day. We highly suspected DKA.
We doctors also over-emphasize to our patients on the dangers of low blood sugar (hypoglycemia) and forget that High Blood sugar is also similarly dangerous. Public education on this matter is needed. Patients should also be advised to own blood sugar measuring machines so that they can properly diagnose themselves for emergency first-aid as they rush to hospital.
I hope this post will help us to prevent sudden deaths in Diabetes .
My patient hopes that his story can help inspire others.
P.S....let us not forget HYPOGLYCEMIA(Low blood sugar) which can also kill in seconds. It is the opposite of this condition I have written about and life can be saved by taking sugar. This requires a whole new post for discussion. I hope to write about it soon.
Have a wonderful March 2016.
