Two serious complications of high blood sugar in people with diabetes are diabetic ketoacidosis, which occurs more commonly but not exclusively in people with type 1 diabetes, and hyperosmolar hyperglycemic state, which occurs more commonly, though still rarely, in people with type 2 diabetes. Although alcoholic ketoacidosis is not caused by diabetes, it is discussed here because of similarities with diabetic ketoacidosis.
Diabetic Ketoacidosis
Diabetic ketoacidosis is an acute complication of diabetes that occurs mostly in type 1 diabetes mellitus. It is caused by uncontrolled high blood sugar. When untreated it can lead to coma, brain damage, and death.
Symptoms of diabetic ketoacidosis include nausea, vomiting, abdominal pain, and a characteristic fruity odor on the breath.
Diabetic ketoacidosis is diagnosed by blood tests that show high levels of glucose, ketones, and acid.
Treatment of diabetic ketoacidosis involves intravenous fluid replacement and insulin.Treatment of diabetic ketoacidosis involves intravenous fluid replacement and insulin.
Without treatment, diabetic ketoacidosis can progress to coma and death.
(See also Overview of Diabetes Mellitus.)
In diabetes, the amount of sugar (glucose) in the blood is elevated.
Glucose is one of the body's main fuels. Insulin, a hormone produced by the pancreas, helps glucose move from the blood into the cells. Once glucose is inside the cells, it is either converted to energy or stored as fat or glycogen until it is needed.
When there is not enough insulin, most cells cannot use the glucose that is in the blood. Because cells still need energy to survive, they switch to a back-up mechanism to obtain energy. Fat cells begin breaking down, producing compounds called ketones. Ketones provide some energy to cells but also make the blood too acidic (ketoacidosis).
Ketoacidosis that occurs in people with diabetes is called diabetic ketoacidosis. Diabetic ketoacidosis occurs mainly in people who have type 1 diabetes because their body produces little or no insulin. However, rarely, some people with type 2 diabetes develop ketoacidosis. People who abuse alcohol also can develop a different type of ketoacidosis (alcoholic ketoacidosis), in which blood glucose levels are usually only mildly elevated.
Causes of Diabetic Ketoacidosis
Diabetic ketoacidosis is sometimes the first sign that people (usually children—see also Diabetes Mellitus (DM) in Children and Adolescents) have developed diabetes. In people who know they have diabetes, diabetic ketoacidosis can occur for 2 main reasons:
People stop taking their insulin
An illness stresses the body
An illness usually increases the body's need for energy. Thus, when people become ill, they often need more insulin to move extra glucose into their cells. If people do not take extra insulin when they are ill, they can develop diabetic ketoacidosis.
Common illnesses that can trigger diabetic ketoacidosis include:
Infections (such as pneumonia and urinary tract infections)
Rarely, some medications, especially the sodium-glucose co-transporter-2 (SGLT-2) inhibitors, can cause diabetic ketoacidosis, even in people with type 2 diabetes.
Some people with type 2 diabetes are prone to develop ketoacidosis. This type of diabetes is called ketosis-prone diabetes, but is sometimes referred to as Flatbush diabetes. This type of diabetes is an unusual variant that is more likely to occur in people with obesity and in people of African ancestry.
Symptoms of Diabetic Ketoacidosis
The initial symptoms of diabetic ketoacidosis include excessive thirst and urination, weight loss, nausea, vomiting, fatigue, and—particularly in children—abdominal pain. Breathing tends to become deep and rapid as the body attempts to correct the blood’s acidity. The breath has a fruity odor similar to nail polish remover because of the smell of the ketones escaping into the breath. Without treatment, diabetic ketoacidosis can progress to coma and death (especially in children).
Diagnosis of Diabetic Ketoacidosis
Blood and urine tests to determine levels of glucose, ketones, acid, and electrolytes
Doctors diagnose diabetic ketoacidosis by measuring the level of ketones and acid in the blood and urine. People with diabetic ketoacidosis also have high blood glucose levels, but people may have high glucose levels without having diabetic ketoacidosis.
Doctors typically also do tests, such as a chest x-ray and urine analysis, to look for an underlying infection and electrocardiography (ECG) to look for a heart attack.
Treatment of Diabetic Ketoacidosis
Intravenous fluids and electrolytes
Intravenous insulinIntravenous insulin
Diabetic ketoacidosis is a medical emergency. Hospitalization, usually in an intensive care unit, is necessary. Large amounts of fluids are given intravenously along with electrolytes, such as sodium, potassium, chloride, and sometimes phosphate, to replace those fluids and electrolytes lost through excessive urination.
Insulin is generally given intravenously so that it works quickly and the dose can be adjusted.
Blood levels of glucose, ketones, and electrolytes are measured every few hours. Doctors also measure the blood’s acid level. Sometimes, additional treatments are needed to correct a high acid level. However, controlling the levels of glucose in the blood with insulin and, giving fluids, and replacing electrolytes usually allow the body to restore the normal acid-base balance. Once blood sugars are closer to normal, dextrose (a type of sugar) is given intravenously in combination with and, giving fluids, and replacing electrolytes usually allow the body to restore the normal acid-base balance. Once blood sugars are closer to normal, dextrose (a type of sugar) is given intravenously in combination withinsulin to stop production of ketones.
More Information
The following English-language resources may be useful. Please note that The Manual is not responsible for the content of the resources.
American Diabetes Association: Comprehensive information on diabetes, including resources for living with diabetes
Breakthrough TD1 (previously called JDEF, or Juvenile Diabetes Research Foundation): General information on type 1 diabetes mellitus
National Institute of Diabetes and Digestive and Kidney Diseases: General information on diabetes, including on the latest research and community outreach program
Hyperosmolar Hyperglycemic State (HHS)
(Nonketotic Hyperosmolar Syndrome; Nonketotic Hyperosmolar Coma)
Hyperosmolar hyperglycemic state is a complication of diabetes mellitus that most often occurs in type 2 diabetes. It involves very high blood sugar and dehydration. When untreated it can lead to coma, seizures, and death.
Symptoms of hyperosmolar hyperglycemic state include extreme dehydration and confusion.
Hyperosmolar hyperglycemic state is diagnosed by blood tests that show very high levels of glucose, sodium, and other substances.
Treatment is intravenous fluids and insulin.Treatment is intravenous fluids and insulin.
Complications include coma, seizures, and death.
(See also Diabetes Mellitus.)
There are 2 types of diabetes mellitus, type 1 and type 2. In type 1 diabetes, the body produces almost no insulin, a hormone produced by the pancreas that helps sugar (glucose) move from the blood into the cells. In type 2 diabetes, the body produces insulin, but cells fail to respond normally to the insulin. In both types of diabetes, the amount of sugar (glucose) in the blood is elevated.
When type 2 diabetes is untreated for a long time, the blood glucose levels can become extremely high (even exceeding 1,000 milligrams per deciliter [mg/dL], or 55.5 millimoles per liter [mmol/L] of blood). Such very high blood glucose levels cause the person to pass large amounts of urine, which eventually causes severe dehydration. However, unlike in type 1 diabetes, the person usually produces enough insulin to prevent the body from producing ketones and developing diabetic ketoacidosis. However, because of the dehydration and high blood sugar, blood levels of sodium and other substances also rise, making the person's blood abnormally concentrated (hyperosmolar). Thus, the disorder is called hyperosmolar hyperglycemic state.
Causes of Hyperosmolar Hyperglycemic State
Hyperosmolar hyperglycemic state can occur for 2 main reasons:
People stop taking the medications for their diabetes
An infection or other illness stresses the body
Also, certain medications, such as steroids (sometimes called glucocorticoids or corticosteroids), can raise blood glucose levels and cause hyperosmolar hyperglycemic state. Medications such as diuretics, which people often take to treat high blood pressure, can worsen dehydration and trigger hyperosmolar hyperglycemic state.
Symptoms of Hyperosmolar Hyperglycemic State
The main symptom of hyperosmolar hyperglycemic state is a mental change. The change ranges from mild confusion and disorientation to drowsiness and coma. Some people have seizures and/or temporary partial paralysis that resembles a stroke. Other symptoms that may precede the change in mental state include frequent urination and extreme thirst.
Diagnosis of Hyperosmolar Hyperglycemic State
Blood tests to measure glucose level and overall concentration of the blood (osmolarity)
Doctors suspect the diagnosis of hyperosmolar hyperglycemic state when people who have recently developed confusion are found to have a very high blood glucose level. They confirm the diagnosis by doing additional blood tests that show very concentrated blood and low ketones or acidity in the bloodstream.
Treatment of Hyperosmolar Hyperglycemic State
Fluids and electrolytes given by vein
Insulin given by veinInsulin given by vein
Hyperosmolar hyperglycemic state is treated much like diabetic ketoacidosis. People must be hospitalized, usually in an intensive care unit. Fluids and electrolytes must be replaced intravenously. Usually, people are given insulin intravenously so that it works quickly and the dose can be adjusted. The level of glucose in the blood must be restored to normal gradually to avoid sudden shifts of fluid within the brain. The blood glucose level tends to be more easily controlled than in diabetic ketoacidosis, and blood acidity problems are not severe.
Alcoholic Ketoacidosis
Alcoholic ketoacidosis is a complication of alcohol use and starvation that causes excess acid in the bloodstream, resulting in vomiting and abdominal pain.
(See also Diabetes Mellitus.)
People who consume a lot of alcohol during one occasion often vomit repeatedly and stop eating. If the vomiting and starvation go on for a day or more, the liver's normal stores of sugar (glucose) decrease. The low glucose stores combined with lack of food intake cause low blood glucose levels. The low blood glucose levels lead to decreased insulin secretion. Without insulin, most cells cannot get energy from the glucose that is in the blood. Cells still need energy to survive, so they switch to a back-up mechanism to obtain energy. Fat cells begin breaking down, producing compounds called ketones. Ketones provide some energy to cells but also make the blood too acidic (ketoacidosis). This ketoacidosis is similar to the ketoacidosis that occurs in diabetes except that, unlike in diabetic ketoacidosis, blood glucose levels are low or normal.
Symptoms of Alcoholic Ketoacidosis
Symptoms of alcoholic ketoacidosis include:
Excessive thirst
Nausea
Vomiting
Abdominal pain
Breathing tends to become deep and rapid as the body attempts to correct the blood’s acidity. Similar symptoms in a person with alcohol use disorder may result from acute pancreatitis, methanol (wood alcohol) or ethylene glycol (antifreeze) poisoning or diabetic ketoacidosis. The doctor must exclude these other causes before diagnosing alcoholic ketoacidosis.
Diagnosis of Alcoholic Ketoacidosis
Blood and urine tests
Doctors base the diagnosis on the characteristic symptoms and their relation to alcohol abuse combined with laboratory test results that show increased amounts of ketones and acid in the bloodstream but normal or low blood glucose levels.
Treatment of Alcoholic Ketoacidosis
Thiamine and other vitamins and minerals given by veinThiamine and other vitamins and minerals given by vein
Intravenous saline and glucose
To treat alcoholic ketoacidosis, doctors give people thiamine (vitamin B1) by vein (intravenously) followed by intravenous saline and glucose solution. Other vitamins and minerals, such as magnesium and usually potassium, are added to the saline solution.To treat alcoholic ketoacidosis, doctors give people thiamine (vitamin B1) by vein (intravenously) followed by intravenous saline and glucose solution. Other vitamins and minerals, such as magnesium and usually potassium, are added to the saline solution.
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