Unintentional lack of insulin usually results from the need for more insulin in certain situations including illness, puberty, and other unique circumstances. During illness, it is important to keep well hydrated and test blood sugars frequently even if you are not eating. Blood sugar levels may increase despite a lack of exogenous carbohydrate, leading to DKA. Other typical reasons for an increase in blood sugar may be due to lack of bolusing of insulin for carbohydrates and malfunctioning insulin pumps. It is important to vigilantly monitor blood sugars while on an insulin pump due to the possibility of a kink in the tubing, a bad site, disconnection, or technical glitch in the pump itself. Unfortunately, if you monitor blood glucose infrequently, you may not realize that insulin has not been delivered for a significant amount of time leading to DKA. Another pump issue that often leads to DKA is changing the site before bedtime. It is a good idea to change the site earlier in the day to ensure that insulin is flowing and that blood sugars are controlled. Children's diabetes team strongly discourages site changes at night to prevent this problem.

Frequent episodes of DKA may lead the healthcare team to consider the diagnosis of "brittle diabetes." Brittle diabetes is actually very rare and it is often difficult to manage despite adequate education and medical treatment. It is difficult to understand the root cause of the problem and often requires extensive discussions with the patient and family to uncover deep-seated issues, thus leading to unstable diabetes. People rarely have true unstable diabetes that requires intensive medical intervention to determine the reason for blood sugar variability and rapidity of the development of DKA. There is usually a reason for the frequent DKA episodes if the diabetes team takes the time and appropriate steps to uncover the underlying, often interplaying, factors.

I hope this discussion leads to a better understanding of DKA and its origins, as well as the means to hopefully prevent this serious and possibly fatal consequence of uncontrolled diabetes. Feel free to ask questions; I am happy to respond.