TOPIC:Monitoring(ketones)Prevention,Detection andTreatment ofAcuteComplications(How and whento treat forketones)TEACHING OBJECTIVES:1. Discuss when ketone

measurement should be done.2. Introduce method to be used

for measuring ketones.3. Present the appropriate time to

call the healthcare provider.

LEARNING OBJECTIVES:Learner (parents, child, relativeor self) will be able to:1. Define ketones and the

importance of ketone testing.2. Identify and demonstrate when

and how to test for ketones.3. State the appropriate time to

call the healthcare provider.

Chapter 5

Ketone Testing

KETONESKetones are chemicals which appear in the urine and blood

when body fat is used for energy. Ketones are a side product offat breakdown (see Chapter 15).

Body fat is used for energy

l when there is not enough insulin to allow sugar to beburned as energy in the body.

l when not enough food has been eaten to provide energy.

Ketone testing is VERY important. A method of testingfor ketones must be kept in the home (and taken on trips) at alltimes.

We usually teach families how to do the urine ketone teston the first day of diagnosis of diabetes. Frequent urine ketonetests are important in the first few days after diagnosis todetermine if enough insulin is being given to turn off ketoneproduction. Turning off ketone production is the first goalin the treatment of newly diagnosed diabetes managed inthe outpatient setting. This usually takes one or two daysafter starting insulin.

The second goal is to lower blood sugar levels (doneprimarily by turning off internal sugar production in the liver).This usually takes one or two weeks after starting insulin.Giving insulin helps to accomplish both goals.

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30 Chapter 5 Ketone Testing

REASONS FOR TESTING FOR KETONES

It is important to test for urine or bloodketones because they can build up in the body.This can result in one of the two emergencies ofdiabetes, acidosis or ketoacidosis (see Chapter15). In the past, it was only possible to test forurine ketones. The Precision Xtra meter isnow available to do a home fingerstick test forblood ketones. The diabetes care providershould be notified when the urine ketone testshows moderate or large ketones or if the bloodketone test is above 1.0 mmol/L.

Usually extra insulin is taken to help makethe ketones go away. If the ketones are notdetected early, they will build up in the bodyand ketoacidosis will result. This is particularlytrue during illnesses. Early detection of ketonesand the treatment with extra rapid-actinginsulin (Humalog/NovoLog/Apidra) can helpprevent hospitalizations for ketoacidosis (seeChapter 15). Hospitalizations for ketoacidosisare still listed as the number one reason forhospitalizing children in the U.S. with knowndiabetes. It is our belief that thesehospitalizations for ketoacidosis arecompletely preventable. To accomplish this,the ketone testing must be done, thediabetes care provider called when indicated,and extra shots of insulin given.

WHEN TO TEST FORKETONES

Ketones must always be checked if theblood sugar is high (above 240 mg/dl [13.3mmol/L] fasting, or above 300 mg/dl [16.7mmol/L]) during the day. They must also bechecked ANYTIME THE PERSON FEELSSICK OR NAUSEATED (especially if he/shevomits, even once). If the person is sick,ketones can be present even when the bloodsugar is not high.

CALL YOUR DIABETES CAREPROVIDER NIGHT OR DAY IFMODERATE OR LARGE URINEKETONES ARE PRESENT OR FORBLOOD KETONES 1.0 MMOL/L.TELL THE PERSON ANSWERING THEPHONE THAT THE CALL IS URGENT.

People who have been recently diagnosedwith diabetes usually need to check ketones twicedaily (or more often if they are positive). Afterthe first few days, if all ketone checks have beennegative, daily testing of ketones is not needed.

People who take only one insulin injectionper day should do routine morning blood orurine ketone tests to see if their insulin is lastinga full 24 hours. Morning ketones will usuallybe present if an insulin injection is needed inthe evening.

Table 1Comparison of Blood Beta Ketone and Urine Ketone Readings *

Blood (mmol/L) Urine< 0.6 negative0.6 to 1.5 small to moderate1.6 to 3.0 usually large 3.0 go directly to the E.R. very large

* The blood and urine ketone values do NOT always agree. The urine may have been in thebladder for several hours. The blood levels tell what the ketones are at the moment the test isdone. (Also read the second Q and A at the back of this chapter.)

The healthcare provider should be called for all values > 1.0 mmol/L in the blood or if theurine ketones are moderate or large.

Chapter 5 Ketone Testing 31

WHAT TEST MATERIALSARE AVAILABLE?Testing for Urine Ketones

The two strips that are most frequently usedin checking for urine ketones are the Ketostix

and the Chemstrip K. If the child is not yettoilet trained, it is usually best to press a test strip(see section on Ketostix) firmly against the wetdiaper. It is also possible to place cotton balls inthe diaper where the diaper is wettest. Drops ofurine can then be squeezed from the cotton ball.

KetostixThe Ketostix (or

Ketodiastix with the sugarcheck) is reliable for urinetesting IF THEY ARECAREFULLY TIMEDWITH A SECONDHAND ON A CLOCK.The Ketostix are cheaperthan the Ketodiastix and itis not necessary to do theurine sugar, as a bloodsugar is more accurate.There is a place on the side of the bottle towrite the date the bottle is opened. The stripsare then good for six months. Individually foil-wrapped Ketostix will not expire for two orthree years. This gets around the problem ofhaving to throw any unused Ketostix away oncethe bottle has been open for six months. Askyour pharmacist to order them if he/she doesnot have them. The Bayer product number forordering is 2640 (20 foiled strips).

The following procedure must be followed exactly:

1. Completely cover the colored square on theend of the strip by dipping into FRESHurine. Then immediately remove the stripfrom the urine. We prefer that the urine becollected in a cup and that the strip then betimed and read by two people. Thisprevents errors due to color blindness orpsychologic factors. A supply of small papercups might be kept in the bathroommedicine cabinet for this purpose.

2. Gently tap the edge of the strip against theside of the urine container to remove excessurine.

3. Compare the test area closely with thecorresponding color chart. The timing isvery important. READ KETONES ATEXACTLY 15 SECONDS AFTERDIPPING THE STRIP. HOLD THESTRIP CLOSE TO THE COLOR BLOCKAND MATCH THE COLORSCAREFULLY. These tests must always betimed with the second hand of a clock.Counting is NOT accurate enough.

4. Immediately record the result of the ketonetest as negative, small (15), moderate (40),large (80) or large-large (160) in thenotebook so that it is not forgotten.

Chemstrip KThe Chemstrip K (or Chemstrip uGK with

the urine glucose check) is the second methodthat can be used to check for urine ketones.The only difference from the instructions forthe Ketostix is in the timing. Chemstrip K mustbe timed for one minute. Read as negative,small, moderate or large at exactly one minute.

Testing for Blood KetonesThe Precision Xtra Meter is the only meter

which allows testing for blood beta ketones.The test strips can be purchased in boxes ofeight foil-wrapped beta ketone strips (see scanof box). Although the blood ketone strips aremore expensive, they do not have to bereplaced (like Ketostix) every six months. Thus,the cost is not all that different. Wheninsurance will not cover the cost of the bloodstrips, some people screen with the urine stripand just do the blood test when the urine test ismoderate or large.

Steps:

1. The red control strip must first be insertedto calibrate for beta ketones. Make sure thecalibration code on the red calibration stripmatches the code on the ketone strip.

2. Open a strip and place it into the meter with

32 Chapter 5 Ketone Testing

the three black bars facing up. Push thestrip completely into the test port of themeter until it stops.

3. After washing and drying the hand, lancethe finger.

4. Place a drop of blood into the purple holeon the strip.

5. The result is then displayed on the meter in10-20 seconds (new improved meter).

We suggest interpreting the readings asfollows (in mmol/L):

< 0.6 = normal

0.6 1.0 = slightly elevated. Drink extrafluids.

1.0 3.0 = serious and call healthcareprovider and state the call isurgent. Take extra rapid-actinginsulin and drink extra fluids.

> 3.0 = Go directly to the EmergencyRoom. Have someone takeyou!

A doctor in Boston (Dr. Lori Laeffel)showed that youth who were sick were 53percent likely to check urine ketones and 93percent likely to check blood ketones. Thesaving of one hospitalization from treatingketones earlier would save 5,000 to 10,000dollars.

DEFINITIONSChemstrip K: Strips for measuring urineketones (acetone). They are also available asChemstrip uGK (for urine ketones and sugar).

Ketoacidosis (Acidosis): What happens in thebody when not enough insulin is available.Blood sugar is usually high at this time.Moderate or large ketones are present in theurine as well as in the body. This is the subjectof Chapter 15.

Ketostix: Strips for measuring urine ketones(acetone). They are also available as Ketodiastix(for urine ketones and sugar).

Ketones (Acetone): The chemicals that appearwhen not enough insulin is present and fat isbroken down. Acetest tablets, Ketostix orChemstrip K measure urine ketones. ThePrecision Xtra measures blood beta ketones.

mg/dl: Milligrams of material in a measuredamount (100cc). Blood sugar (glucose) levelsare expressed in these terms in the U.S., butthey are usually expressed as mmol/L inEurope. It is possible to convert mg/dl tommol/L by dividing by 18 (or multiplying by0.0555). The opposite is done to go frommmol/L to mg/dl. A conversion table forglucose values is in the Appendix.

mmol/L: Method of measuring the amount ofa material (sugar or ketones) in the blood. Thismethod is usually used in Europe. See mg/dlfor conversion factor for sugar (and the table inthe Appendix).

Void: Passage of urine.

Chapter 5 Ketone Testing 33

QUESTIONS AND ANSWERSFROM NEWSNOTES

Why are you now advising that webuy the foil-wrapped rather thanthe bottles of Ketostix for

measuring urine ketones?

You will note that on the side of abottle of Ketostix, you are asked towrite in the date the bottle is opened

and to dispose of the bottle six months later.Sometimes people forget to do this. Once thebottle is open, moisture and other factors resultin a gradual loss of sensitivity. Often, a fluepisode will start in the middle of the night. Asone looks at the date on the side of the bottle,if the strips have been open longer than sixmonths, they are unreliable. Similarly, if a datewas not recorded, it is usually necessary toassume that the strips have been open morethan six months. They then must be discarded.Then one has to go looking for an openpharmacy in the middle of the night. The foil-wrapped Ketostix avoids this problem. Theymay have an expiration date two years away.The expense is not all that different if oneconsiders replacement of the urine strips everysix months.

Ketone measurements are VERY important.A method for ketone testing MUST be in thehome at all times. It is ONLY by measuringthe ketones that one can know if moderate orlarge urine ketones or high levels of ketones inthe blood are present. If present, the physicianmust be called immediately. This may prevent alife-threatening episode of ketoacidosis(Chapter 15).

We recently obtained a Precision Xtrameter that measures the bloodketones as well as the blood sugars.

How do the blood ketone measurementscompare with the urine ketone measurements?When do we need to call our doctor or nurse?

Like a blood sugar measured on ameter, the blood (serum) ketone valuegives the ketone level at the time the

test is done. The urine ketone measurement,like a urine sugar, can be hours behind. (Theurine collected is since the last void.) Theblood ketone value has the potential to bebetter than the urine ketone measurement.

I am not aware of studies comparing theserum ketone (primarily beta-hydroxy butyricacid) with the urine ketone (primarilyacetoacetic acid) levels. The company notesthat levels below 0.6 (all values are in mmol/L)are considered normal levels, in the 0.6 to1.5 range are considered moderate and levelsfrom 1.6 to 3.0 are considered high(probably similar to large urine ketones).Levels above 3.0 should be considereddangerous with a need to head to a hospital(DKA Chapter 15). It is most beneficialwhen sequential blood levels are donethroughout the day so that the family can knowif values are increasing, staying the same ordecreasing. The test is particularly helpful whena person cannot void frequently due todehydration, or when a person does void for thefirst time in a number of hours, so that it is notpossible to tell if the urine ketone measurementrepresents the current level. It would be wiseto routinely call the diabetes care provider whenvalues above 1.0 are obtained. As an addednote, please remember to check the calibrationcode when you use a new batch of the ketonestrips. The red calibration stick needs to matchthe code on the ketone strip you are using.

It has been shown that youth are morelikely to check blood ketones with an illness (93percent did) than to check urine ketones (only53 percent did). Finding ketones earlier couldsave a 5,000 to 10,000 dollar hospitalization(OR A LIFE!).

Q

A

Q

A

34

Who is low?