Ketoacidosis

Introduction

Ketoacidosis is a metabolic disorder associated with pathologically elevated serum and urine levels of ketone bodies[1]. Ketoacidosis is a serious life-threatening condition[2].[3]

Clinically relevant forms of ketoacidosis include:

1. Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of uncontrolled diabetes.
2. Alcoholic ketoacidosis (AKA) occurs in patients with chronic alcohol abuse liver disease and acute alcohol intake.
3. Starvation ketoacidosis occurs after the body has absorbed glucose as its primary energy source for a prolonged period of time causing fatty acids to replace glucose as the primary metabolic energy source.[1]

Etiology

1. DKA can occur in patients with diabetes mellitus, which is often associated with mild insulin resistance. This may be due to acute physiological stress or in some cases may be an earlier clinical manifestation in patients with previously undiagnosed diabetes. Some of the most common risks potential precipitating factors for severe hyperglycemia and subsequent ketoacidosis are bacterial resistance to insulin therapy major severe diseases such as myocardial infarction sepsis pancreatitis stress trauma and exposure to certain drugs e.g. glucocorticoids or atypical antipsychotics with effects on carbohydrate metabolism.[1]
2. AKA occurs in patients with chronic alcoholism. Patients may have a history of long-term alcohol use, or they may develop alcoholism. Acetic acid is a product of alcohol metabolism and a substrate for ketosis. Conversion to acetyl CoA and subsequent entry into Various pathways or cycles, one of which is the ketogenic pathway, depend on the ratio of insulin availability to counter-regulatory hormones.
3. Under normal conditions, cells rely on free blood sugar as their primary source of energy, which is regulated by the insulins glucagon and somatostatin. As the name implies, starvation ketoacidosis (such as an eating disorder) is the body’s response to prolonged fasting hypoglycemia that reduces insulin secretion Biochemical shunting to lipolysis and oxidation of by-product fatty acids to ensure a fuel source for the body[1].

Epidemiology

1. DKA is often associated with type 1 diabetes, but it is not uncommon in some people with type 2 diabetes. Approximately 30% of children and adolescents with newly diagnosed type 1 diabetes develop diabetic ketoacidosis at their first presentation [2]
2. For AKA, prevalence was associated with incidence of alcohol abuse without differences in incidence by race or sex. It can occur at any age and occurs mainly in chronic alcoholics, but rarely in alcoholics.
3. With starvation ketosis, mild ketosis usually occurs after 12 to 14 hours of fasting. Without a food source, such as in situations of extreme socioeconomic deprivation or eating disorders, this will cause the body’s biochemistry to gradually shift from ketosis to ketoacidosis. possible Seen in cachexia, dysphagia and long-term poor eating in patients with underlying malignancy after surgery or radiation therapy. [1]

Presentation

On physical examination, most patients with ketoacidosis present with features of hypovolemia due to gastrointestinal or renal fluid and electrolyte losses. In severe cases, patients may experience hypotension and significant shock. They may have a rapid and deep breathing effort as a compensatory mechanism Called Kussmaul breathing. Their breath may have a distinctly fruity smell, mainly due to the production of acetone. [1]

1. DKA: Without enough insulin, body cells cannot use glucose for energy. To compensate for this, the body starts burning fat for energy. This causes dangerous chemicals called ketones to build up in the blood, which also show up in the urine. high blood sugar levels and Moderate to severe ketones in urine:
   • Rapid breathing
   • Flushed cheeks
   • Abdominal pain
   • A sweet acetone (similar to paint thinner or nail polish remover) smell on your breath
   • Vomiting
   • Dehydration[3].
   • In a minority of children, DKA is complicated by central nervous system damage. These children have high rates of mortality and long-term neurological disease. Cerebral edema is the most common neuroimaging finding in children with DKA and may lead to brain herniation. [4]

2. AKA patients may have withdrawal signs such as hypertension and tachycardia.

3. Patients with starvation ketoacidosis have signs of muscle atrophy, such as poor muscle mass, low body fat, prominent bony protrusions, temporal atrophy, tooth decay, sparse and dry hair, low pulse and body temperature[1].

Treatment

1. DKA is a medical emergency, and institutions usually have established protocols for emergency management. But the principles of treatment should be the same:

• Correct volume depletion with IV fluids
• Correction of hyperglycemia with short-acting insulin infusions
• Potassium and other electrolyte correction
• Search for the underlying cause

In developed countries, the overall mortality rate from diabetic ketoacidosis is 2.5-5%. [2]

2. AKA usually responds to intravenous saline and intravenous glucose therapy, with rapid clearance of associated ketone bodies due to reduction of counter-regulatory hormones and induction of endogenous insulin. Thiamine substitutes are important in alcohol-related manifestations. Electrolyte replacement is critical. [1]

3 The treatment of starvation ketoacidosis is similar to that of AKA. Patients need to be monitored for refeeding syndrome, which is associated with electrolyte abnormalities that occur when chronically starved individuals begin to actively eat. The resulting insulin secretion causes Significant transcellular transfer is therefore important similar to AKA monitoring and substitution of potassium and magnesium phosphates. [1]

Physiotherapy

Treatment of ketoacidosis depends on the specific pathophysiology diagnosed. Regardless of the specific cause, it is important for a physical therapist to understand the condition.

DKA relevance:

• Educate clients about DKA.
• Maintaining normal glucose levels can prevent DKA.
• Physiotherapists are in a unique position because of the amount of time we spend with patients and it is important that we play a role in looking after their well-being and being aware of the symptoms of DKA

Ketogenic Diet

The ketogenic diet is enabled by forcing the body into a state of ketosis. This happens as a result of eating too few carbohydrates and too many fatty foods. Instead of using glucose from carbohydrates, the body will now continue to use the stored amount of fat in the body for energy. People often use this diet to help them lose weight.

There have been cases of ketoacidosis caused by keto diet and oral ketone supplements. Although some studies have shown significant weight loss when using a ketogenic diet the negative consequences of such a diet need to be emphasized. In patients at risk such as those with diabetes and/or CKD, caution should be given against the use of exogenous ketone supplements that are not usually as extensively regulated as Food and Drug Administration-approved drugs. Patients should be counseled on the risks of taking these unregulated weight loss products[5].