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Trying to understand DKA

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mum25

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Parent of person with diabetes
hi all
I posted a couple of days back, our daughter is very newly diagnosed T1 and I have questions galore running around my head. Hoping for some sense of clarification from the people with more experience rather than the text books.

1) How does DKA become DKA rather than showing the typical signs of T1?
2) Do all T1 have honeymoon? Our daughters levels are consistently higher now than when she was admitted, she's hungry all the time. Tonight bg was 30.2, she's on humalog mix and having 24 am and 11 overnight. No ketones and apart from wetting once overnight and very emotional she's doing well. DSn talking about changing her to more injections for better control.

Thanks for any explanations and support.
 
Hi Mum25, I will try and explain simply, because it can become complicated! DKA occurs primarily due to a lack of insulin, which is why many type 1s have DKA when diagnosed - they are no longer producing much, if any, insulin. When you don't have enough insulin circulating in your system you can't use the glucose in your blood for energy, so your body will start to convert fat and muscle tissue to provide energy. This process produces a by-product called 'ketones'. This is actually a natural process, and is what happens when we want to lose weight by dieting and using up our fat reserves for energy, and is known as 'ketosis'. However, in order to successfully remove these ketone by-products from the blood we need sufficient insulin to be available, otherwise they will build up in the blood. As the ketones are acidic in nature, too many ketones can start to turn the blood acidic, and this is when it becomes 'ketoacidosis' and potentially dangerous.

So, the key is whether there is enough insulin available to use the glucose in the blood and process the ketones - if there isn't then blood sugar levels will climb high, as will the amount of ketones. Once more insulin is given the glucose in the blood can be used, the process of using fat and muscle slows, ketones reduce and are also processed out of the system 🙂 It should be borne in mind that it's perfectly possible to have a low level of ketones and be perfectly OK - it's usually when you haven't eaten for a while. It's when they build up, and especially in the presence of high blood sugars, that there can be a problem that requires action.

The difficulty you currently have is that, on a mixed insulin it is hard to 'correct' a high blood sugar level without causing other problems, due to the fact that you are not only giving extra fast-acting insulin (needed to bring the levels down quickly), but also some slow-acting insulin, which you don't really want to give as this will exert an effect for several hours and make subsequent calculations much harder. I would hterefore highly recommend that you take up the DSN's suggestion of moving to MDI (Multiple Daily Injections) which involves using separate fast and slow acting insulins. It will also give you much more flexibility around mealtimes and snacks and hopefully make things more intelligible and predictable 🙂 Note that when a person is poorly this can make the person more insulin-resistant, so DKA can often be a problem when poorly as there can be insufficient insulin available (this is why a lot of people get diagnosed when they are poorly with a virus, which then results in DKA making things even worse).

The following document is a useful guide to treating sickness when on MDI:

http://www.uclh.nhs.uk/PandV/PIL/Pa...ick day rules – multiple daily injections.pdf

If you don't have them already, request a meter that can read blood ketones, and some blood ketone strips. The blood ketone strips are much more accurate than urine strips, and give you a result in 'real-time' - urine strips only show the situation about two hours after the blood levels and are harder to read, being down to shades of colour.

Regarding honeymoon periods, this can vary so much from person to person, so it's not really possible to generalise, unfortunately. The hunger is normal soon after diagnosis - I was ravenous for a few weeks after my diagnosis, but things did settle down eventually. Basically, your body has been struggling for so long as your insulin production declines, it goes a bit mad when you start getting a plentiful supply again from the injections!

Definitely go for the extra injections! 🙂
 
Hi Mum25
DKA is caused by the body breaking down fat because it can't use the glucose in the blood (due to lack of insulin) and believes it's in starvation mode. The K and the A stand for Ketoacidosis, ketones (the keto bit) are produced when the body breaks down fat and in someone with a fully functioning pancreas are harmless because they're excreted by the body. Much less insulin is needed to deal with ketones but there's still some needed, so us type 1 folk end up with a very high level of ketones because we don't produce any insulin or if we do not nearly enough to support our bodies needs. Ketones in high quantities make the blood acidic (we are naturally Ph neutral, well almost!) which is what the acidosis refers to. So high blood sugar isn't the cause of DKA exactly, starvation is because the body will only resort to fat consumption if it's desperate (which is why it's so hard to lose weight 🙄). Your daughter now has circulating insulin because it's being injected so her body can use the ketones as an alternative source of food and they aren't building up in her blood stream (so no acidosis). Does that make sense?

In terms of a honeymoon, I don't think every newly diagnosed child or adult gets one, I didn't (I was an adult), but it's probably a bit soon to know with your youngster. It takes the body a while to stabilise because the body also becomes glucotoxic when in DKA and there's glucose deposits everywhere. I'll let some of the parents tell you what it's like for kids because it may well be different, but mixed insulin is generally not recommended for T1 folk anymore so changing to multiple injections will most likely be a good thing in getting control, that generally means an injection with every meal and one or two injections of background insulin so 5-7 on average. That sounds like a lot I know but it's much more flexible. Hope she's doing OK, and you and her Dad are coping as well (it's a massive change so don't worry if you don't feel like you are) 🙂

That bed time reading probably warrants a conversation with the nurse though, it's very high and I had a similar experience after diagnosis when using mixed insulin, they moved me to another regime and it all fell into place, essentially she'll start to feel better when there's more consistent control so best to talk that over with the nurse.
 
Thanks Northerner and KookyCat, that's clearer in my head. Makes you wonder why they started her on mixed insulin when it's not really recommended anymore. Our Dsn is coming out today so I'll talk to her about changing sooner, they were talking about in a couple of weeks time. Thanks again.
 
We went straight onto MDI with Novorapid and Lantus after diagnosis, I'm surprised they put you on mixed! The advantage of having long acting and short acting separately is that if something does go a bit wrong and you end up with a really high reading you can inject some extra to bring it down again. You can't do that with mixed as you would be injecting the long acting too and that would have an effect for 24 hours afterwards! Also you can be much more flexible with mealtimes, injecting just before you eat, and hopefully they will also eventually teach you carb counting so that you can inject exactly the right amount of insulin for the food (and therefore be much more flexible over what your daughter eats as well as when). They might wait a little while before going into all that though as it's a lot to take on board all at once!

Your daughter is hungry because her body has had quite a battering recently, it was literally starving and fighting to stay alive for the weeks prior to diagnosis; now she can use her food properly again her body is rebuilding itself. The hunger will subside after a few weeks, don't worry!
 
Hi Mum25

I was diagnosed as an adult, and had a honeymoon period. This was described to me as a time when I still had some beta cells which make insulin, but at diagnosis these had given up (I know this is not a medical description) as they were having to work so hard. Once I was injecting insulin these got a bit of a rest, and then, during the time that the antibodies had not got round to destroying them, they would decide to have another play. No warning so then I would go low, adjust my insulin, then they would pack up again or more got destroyed.

To summarise my control was a bit up and down during the first year, but definitely easier with the Multiple Daily Injections (rather than just two mixed ones). I am not sure whether the honeymoon period is the same for youngsters but you could ask the DSNs.

Keep in touch with us and let us know how your daughter gets on.
 
Hi Mum25, Sounds like you've had some good answers there, my daughter was diagnosed at 11 months, that was 31 years ago so I wont go into any details as insulin regime was much different then. Just wanted to say hi, take in as much as you can, it will get easier, you will of course have some tough times as well, but it sounds like you are preparing yourself well for them and I'm sure you will both do fine. Good luck Al
 
I'm appalled that she's been given mixed insulin at all, frankly. It still does have it's uses in an emergency I'm sure - ANY insulin is always better than NONE, of course!

But since this was AFTER they'd dealt with the emergency, WHY?

I know exactly what they say for newly diagnosed Adults, but not sure at all about kiddies - so I'm off to Google NICE for that and I'll report back if I find anything useful.........
 
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