First time I've had DKA - don't want it again!

Well, first time for everything and all that. But DKA finally paid me a visit in all 34 years of dealing with this. And frankly still annoyed over it.

The day started pretty well. Early rise, all kitted up and prepped for the event today (62 mile cyclocross with 8824ft of climbs). Bloods were pretty perfect for it, 6.2 (111 in US money) had breakfast on a 60% bolus as usually and off rode to the start of the event. Was a little slow getting away so by about 8 miles into the event bloods where up to 16.2 (291) and I corrected partially and by the first food stop at 22 miles in bloods where down to 5.6 (101). For the remainder of the event everything was fine blood wise with little deviation (5.2-5.8 throughout) and completed it at 5.6. Was a hard slog, shaved a good chuck off my previous best time, met a load of folks who I got chatting to, and over all really had a good time.

Rode home, bloods where 5.2 (94), washed bike and back tyre went flat grr. I'll sort that later so kind of ignored it and finished up cleaning and got myself cleaned up for the coating of mud I was covered in.

A few hours later checked for dinner and eep BG was up to 16.1 (290), corrected, had a little feed and waited and had a splitting head ache which was odd and BG was 20.4 (367). Massive correction and an couple hours later 17.1 (308). I started vomiting which was odd and couldn't work out why. Didn't seem to be dinner related but made me think anyhow but blamed being so high for it. Really fed up with it all now changed vile, infusion set and usual things and started again. Did a correction and waited an hour and now 17.8 (320). Utterly fed up even tried using pens, BG now 17.2 grr. Ok this has lasted long enough lets check for ketones..ACK 5.0. That's it, something not working, I feel awful and I need help so got a lift to hospital.

By time I got to hospital BG was still 17.8 (320) but ketones where now up to 5.8. Blood pH had now dropped to 7.33. BG kept around 17 for the next 4 hours or so and ketones raised to 7.8 before everything started to come down. Took 23 attempts though to get cannula's into me for insulin, food, and hydration mix (massively low potassium in blood it seemed, blamed on possibly lack of hydration in ride but thought I had drunk enough *shrug* with over a couple a bottles) due to veins collapsing though.

ECG and Xray wasn't showing a possible cause and blood work up seemed to only indicate white blood cells high attacking something. So some dodgy infection caused it.

Anyhow, long story short. They fixed me up, got me switched back to my pump. And back home. Ketones have been fluctuating for today between 0.2 and 1.8 with the bloods being kept pretty steady in the 6's. But eating little and often and drinking loads and should be flushed out of me by tomorrow or so's the plan. Arms are a mess now due to the attempts to get stuff into me, and blood out of me.

Utterly annoyed though about needing help! Theory is currently the ride weakened me enough for the infection to cause some mayhem but not over sure which is a concern. Still haven't had the usual recharge moment off the ride which is very odd also. But it's another day being T1. Always finds something "fun" to throw at you and learn from :P

That really messed up such a good ride! Sorry, glad you are better now.

I must admit I did always wonder about DKA and what it was like, and think I was pretty light on just the edge of it mostly compared to how it hits many. Booked in to see my DSN (CDE) on Friday to go through everything but not overly sure what she will make of it. When I called her she was "dka, YOU!" on the phone. Guess that was kind of a compliment.

One word. Dehydration.

This is a big risk in endurance exercise. It isn't just about water. Just drinking water doesn't fix it and can even make it worse. You sweat, you lose electrolytes. If your sodium and potassium drops your insulin doesn't work.

I'm glad you are ok.

Dehydration. Respect.

That was a bit I never fully worked out either. I drank just shy of 2L of water (1.4L of which was carb mix) with a strong hydration tablet mix throughout it. It's the same mix I used on the Tour de France and that was 36C in places (weather on Sunday was 12C at its warmest). Blood work up yes did show little in way of potassium, but sodium levels were fine. I'm still blaming hydration to some degree myself but think it's one of a few elements which combined sadly. Should be an interesting meeting with my DSN and dieticians though *gulp* am expecting a good ripping apart on it.

I think sodium levels are the most critical as sodium plays a central role in glucose uptake. So maybe dehydration was not so significant a factor. You may have actually had some mix of HHS with DKA. A low potassium level often follows DKA/HHS treatment as the large insulin doses deplete potassium levels. A description of the two conditions is here. It doesn't actually sound like you got a specific diagnosis of DKA, they just patched you up and sent you on your way.

I don't think you deserve a ripping apart. Instead I would turn the question around and ask exactly how you were supposed to prepare and handle the situation. I suspect the answer will an extended silence followed by "don't do endurance exercise." If your team can't be helpful they shouldn't criticize.

ps. Your ketones may actually have been partly due to having just exercised and starving since you may not have had much food.

True, except for the blood pH which by time I had reached hospital (ketones at 5.8) it was at 7.33 and by time it peaked at 7.8 it had dropped to 7.18 which is definitely in DKA (over here they have it as a pH less than 7.3).

Interestingly scrutinising much of what I did beforehand, this is the first ride I've ever pre-hydrated as well. Saw a guide recommending large hydration for the two days before a ride so was giving that a go. If anything that should of helped, but am partially wondering if possibly not.

Love to see my team try and stop me riding though but think they know better than that and are usually pretty good. My dieticians are usually pretty handy with one being a touring cyclist and the other treating me as her maths experiment to use all the text books she doesn't get to use often with most patients and "don't eat that" lectures. I usually ride to the hospital (a 96 mile round trip) and only reason I'm not this time is I can feel I haven't recovered yet when I go for the ride on my commute and I just don't have the power yet. Think it'll surprise my DSN (CDE) to see me not in lycra for once.

Taking all data though, as well as normal bloods, food, ketone reports and the hospital report, also taking my Garmins data covering my heart rate, temps, power output and other data. Usually pretty handy to check things off on but reading it myself thinking I might of over cooked it a bit as my average power output was 85% of my maximum for the entire sportiv which spiked over 105% a couple of times which isn't ever good. So again thinking it shows some interesting data which could all be coming into this.

You might be right about your pre-hydratation? Hydration is really more about getting all your electrolytes in place rather than the amount of water you drink and have on board. Maybe you actually pre-dehydrated.

They basically put it all down to a collection of lots of little things all grouping together to cause it really. No real cause, and did everything by the book and happy I signed myself into hospital and didn't allow it to get to far.

Over all though a slight but if dehydration, along with an infection which seems to be shown in the blood work up which seems to of been given an advantage due to the ride already stretching my system. With also a possibility of a damaged infusion set from the ride all going into causing it all.

Offered me a spot on DAFNE (Dose Adjustment For Normal Eating - the you can do anything, eat anything, be anything course as long as you know how it'll effect you) again, but while I loved the course think it was a bit unfair as so few get a place on it and me going a second time I don't think would be as beneficial as it would be for them. And yet again got roped into being the pump test bunny for the next DSN training course. Always fun demoing pump tech to nurses going through their training.

Brian, I was recently over 500 BG; managed to bring it down by myself with a new Apidra pen and drinking 1 1/2 quarts of water. It was scary. My question: granted that one needs electrolytes, how does one get electrolytes in that kind of situation?

Usually on a ride I have drinks containing electrolyte tablets. Are fairly common things for those doing sports etc.

Hi Nyadach. I ought to get a drink with electrolytes for a low. I was stumped when it came to knowing what to do with the high (which reached 537), with respect to electrolytes, so I just drank water. I guess one could take a glass of the sport drink with a bolus when you were sure that your blood sugar was finally going down.

Question about electrolytes. I have a dog with diabetes and the vet gave him fluids with electrolytes. Is there some way to add those to his water without adding carbs?