Ketones + DKA
What are Ketones? When do they cause DKA?
Sometimes in the busy-ness of life the T1D dragon is overlooked: a missed bolus, a delayed glucose check, or illness can all increase the risk of developing ketones, which can escalate into DKA. To keep our T1D kids safe we need to know what symptoms to watch out for, the difference between “having ketones” and “diabetic ketoacidosis,” when to give extra insulin and when NOT to. Read on for Waltzing the Dragon’s clear, concise chart (based on glucose reading, presence of ketones and your child’s symptoms) to help you easily identify when to deal with ketones at home vs. when to seek medical help immediately.
Ketones are the acidic by-products of the burning of fat as fuel. When there is not enough of either glucose or insulin to support the normal process of using glucose for energy (the preferred fuel source), the body may start to burn fat for energy. If fat is burned, ketones are produced. A large amount of ketones can harm the body.
Ketones may be produced as a result of:
- a lack of insulin – due to:
- significant under-dosing of insulin
- missed dose(s) of insulin
- spoiled insulin (exposed to extremely high, or freezing temperatures, or expired)
- poor absorption
- insulin pump malfunction
- illness, infection, and dehydration, which cause the body to release stress hormones that work against insulin (make your child insulin resistant).
- lack of carbohydrates (extreme low- or no-carb diet; your child has not eaten carbs due to illness).
Signs of the body using fat for energy are:
1. Ketones in the urine or blood (detected as a result of ketone testing).
2. “Ketone breath” (breath smells like sweet nail polish remover).
These symptoms are not, on their own, indicative of a more serious condition called Diabetic Ketoacidosis (DKA). However, if ketones are not dealt with and, as a result, build up in large amounts, they can harm the body by altering the delicate pH balance in the bloodstream and body tissues, leading to DKA, a life-threatening condition.
Therefore, when there is a reason to suspect the presence of ketones, it is important to check the urine and/or blood.
Always check for ketones when:
- The blood glucose is greater than 14.0 mmol/L.
- Your child is ill.
- Your child is nauseous or has vomited.
- Your child has a stomach ache.
Further, the symptoms of Diabetic Ketoacidosis (DKA) are:
3. Loss of appetite, nausea, vomiting, or abdominal pain (in the presence of high blood glucose and ketones)
4. Deep, fast breathing (known as “Kussmaul breathing”)
5. Extreme tiredness leading to unconsciousness
IF YOUR CHILD HAS ANY OF THESE SYMPTOMS OF DKA, YOU SHOULD CONSULT MEDICAL STAFF IMMEDIATELY
If #3 only, a phone call to the urgent line for your child’s diabetes health care team may give you enough information to resolve the situation safely.
If #4, 5, or 6, it is wise to bring your child to Emergency Medical Services immediately.
Ketones vs. DKA
As outlined above, there is a difference between “having ketones” and “diabetic ketoacidosis”. Many people, even those without diabetes, have ketones under certain circumstances. Ketones are something to pay attention to and to monitor for signs of escalation, but if additional risk factors are not present, and if you feel comfortable with your own knowledge and skills, you may choose to deal with them at home, without additional medical support.
Diabetic Ketoacidosis, however, is a very serious situation. It is NOT normal in any population, and always requires immediate medical attention – you should not attempt to deal with DKA on your own at home.
Treatment of Ketones
The degree to which you treat the presence of ketones will depend upon
- the quantity of ketones present,
- your child’s current blood glucose reading, and
- the presence of symptoms that indicate DKA.
|No extra insulin. Drink water. Usual routine.
|Extra insulin needed. Drink lots of water. Monitor at home.
|IMMEDIATE MEDICAL ATTENTION at local hospital / Emergency.
1. Ketones + Target BG + NO signs of DKA:
If your child has ketones but does NOT have high blood glucose, you do not need to give extra insulin to treat the ketones (and, in fact, it would not be wise to do so, or your child's glucose may go low). For example, in the mornings your child may have “starvation ketones” as a result of overnight fasting. Usually, this situation is not accompanied by high blood glucose and is nothing to worry about. Your child’s regular routine of eating and taking insulin should eliminate starvation ketones. Drinking water to “flush out” the ketones will also clear them from your child’s bloodstream.
Tips from the Trenches
There have also been times in our family when my son has been sick and has had ketones, but his blood glucose has been within the target range. This was probably due to the fact that he was not eating, so his body turned to stored fat as fuel. In this case, we simply give him plenty of fluids to keep his body well- hydrated. When he began eating again (and taking insulin for that food), the ketones went away.
2. Ketones + High BG + NO signs of DKA:
If ketones are present at more than trace levels, AND blood glucose is high, your child needs extra insulin.
- For specific dosing instructions, contact your child’s diabetes health care team.
- Your child should not exercise when the blood glucose is high AND ketones are present. Under these conditions, exercise will make the blood glucose go even higher.
- Drinking plenty of water (in the presence of enough insulin) will also help flush out ketones.
3. Ketones + High BG + SYMPTOMS of DKA:
URGENT MEDICAL ATTENTION REQUIRED.
- Bring your child to your local hospital or emergency IMMEDIATELY if he/she has high glucose and shows the following signs: Loss of appetite; nausea; vomiting; or abdominal pain, WITH deep, fast breathing; extreme tiredness leading to unconsciousness; or unconsciousness.
- Do not attempt to deal with symptoms of DKA on your own at home. Your child needs more than just additional insulin and fluids by mouth in order to restore him/her to health. DKA must be treated immediately with intravenous insulin and fluid, as well as electrolyte replacement.
The above information was adapted with permission from The Alberta Children’s Hospital Diabetes Clinic information handouts.
The above information was reviewed for content accuracy by clinical staff of the Alberta Children’s Hospital Diabetes Clinic.
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