LWD - Chapter J

J1. Understanding Ketones: How to Treat Ketones & Avoid DKA

Insulin acts as a key to allow glucose to move from the blood into the cells where it is used as energy. If you have diabetes and do not have enough insulin, the body cannot use glucose properly. The body will try to make its own energy by releasing glucose from its own stores. It also breaks down fat leading to ketone production. The body also produces ketones if you starve for long periods as the body runs out of glucose.

Ketones can provide short term energy but they are acids and can make you feel very ill. Ketones cause insulin resistance which means you need more insulin than usual to have the same effect. If ketones are not treated quickly they can lead to diabetic ketoacidosis (DKA), which is discussed in more detail in section J7. Your body will try to get rid of ketones in the urine and also in your breath. They smell like pear drops but not everyone can smell them.

Early identification and management of rising ketone levels can reduce the risk of DKA.

J2. Situations Where The Body May Make Ketones

Not enough insulin (insulin resistance) = Ketone Production:

• High HbA1c
• Puberty/Growth
• Pump failure
• Illness
• Stress

Not enough glucose = Ketone Production:

• Starvation
• Exercise
• Illness (e.g. diarrhoea and vomiting) 

J2a. Not Enough Insulin (Insulin Resistance)

There are several situations in which either the body does not have enough insulin or the body cannot respond as well to insulin. This causes glucose levels to rise increasing the risk of ketone production.

1. Diabetes associated with high HbA1c (> 69 mmol/mol)

When your HbA1c is high, there is regularly not enough insulin in the body and blood glucose levels are high most of the time.

2. Illness:

Children and young people whose diabetes control is optimised should not experience more illness or infections compared to children and young people without diabetes. However, routine childhood illnesses (e.g. viral infections) can make diabetes management more challenging and increase the risk of DKA. During illness, particularly those associated with high temperatures, the body works much harder and demands more glucose. As the body tries to fight infection it releases stress hormones, which both encourage the body to release more glucose and cause insulin resistance leading to ketones.

Illness can affect glucose levels prior to the onset of the illness, during the illness and for several days after. It is extremely important to monitor glucose levels and ketones when unwell.

3. Growth and Puberty:

During times of rapid growth and puberty the body needs more insulin as the pubertal hormones make your body less responsive to insulin. Young ladies with diabetes will often need more insulin around their periods.

4. Stress:

Like puberty hormones, stress hormones make your body less able to respond to insulin. Stress can occur in lots of situations including illness, if you have hurt yourself (e.g. broken a bone) or school exams.

5. Pump failure:

When you are on a pump, there is no long-acting insulin in the body only short acting insulin. If your pump insulin runs out or your pump is not working properly, your body will not have enough insulin to use glucose effectively. Therefore, one of the first things to consider if you feel unwell or have high glucose levels with or without ketones is ‘is my pump and infusion set working?’

Check for ketones after any unexpected high glucose result. Pump users should follow these rules:

1. Check ketones.
2. Give a ‘sick day/illness management’ correction dose by pen injection if ketones are present.
3. Change pump infusion set or pod to a new site.
4. Check you had not run out of insulin.
5. Check the old cannula was not bent.
6. Check for air in your line.
7. Confirm ketone level after 2 hours is 0.6mmol/L or reducing.
8. Contact diabetes team if no improvement.

J2b. Not Enough Glucose

Ketones will also be produced if there is not enough glucose in the body. These are known as ‘starvation ketones.’ When this occurs your glucose levels may be low or on the lower end of normal range. This tends to be more common in the following situations:

1. Starvation:

If you miss food for long periods, particularly carbohydrates, the body will naturally form ketones for energy once it has used up its own glucose stores.

2. Illness associated with vomiting and diarrhoea (e.g. gastroenteritis)

Illness associated with vomiting and diarrhoea (e.g. gastroenteritis) may lower blood glucose levels especially if you struggle to tolerate fluids and food.

3. Exercise:

Exercise demands energy and if there is not enough glucose from carbohydrate, more fats will be broken down to form ketones. Exercise is good for you but if your blood glucose is high or low and ketones are present you should not exercise until your ketones have gone and blood glucose normalised. This is why the diabetes team will support exercise advice individually with you.

J3. Avoiding Ketones

General tips:

• Try to eat a healthy varied diet at regular intervals.
• Accurate carbohydrate counting is essential.
• Try not to forget insulin. You should aim for 4-7 boluses per day, with food or as corrections.
• Aim for an average glucose of 8mmol/L or below over a two-week period. If higher than this it is likely that your insulin needs review. Please contact the diabetes team if you are unsure what to do.
• Reviewing your data regularly can indicate patterns or trends of elevated glucose, which can highlight the need to change your insulin doses. Reviewing this between clinic appointments is important. Your named nurse will be happy to support data review.

J5. Ketone Management (also known as Sick Day Rules/Illness Management)

The blood ketone and blood glucose level help to determine the specific treatment advised.
Below are the key principles of ketone management. All children and young people with diabetes will receive individualised ketone management plans at your annual review as a minimum.

General Principles

Ketones must be checked if your blood glucose is 14mmol/l and above OR if you feel unwell regardless of your glucose level.

Check your blood glucose and ketones every 1-2 hours. Aim for glucose levels 4-10mmol/L and blood ketones < 0.6 mmol/L.

Contact the Diabetes team URGENTLY if your child has the following symptoms:

• Vomiting – a sign of DKA until proven otherwise
• Abdominal pain
• Fast breathing
• Drowsy or confused
• Struggling to keep glucose levels up

DO NOT STOP INSULIN even if not eating. If glucose is low, insulin may need reducing.

The body needs fluids, food and insulin to stop ketone production. Dehydration affects sensor accuracy.

• If glucose is above 14 mmol/L drink sugar free fluids aiming for 100ml/hour.
• If glucose is below 14 mmol/L carbohydrate containing liquids can be useful (e.g. diluted fruit juice or sugary drinks) with insulin.
• Food should be matched with your usual insulin. If not hungry replace food with small amounts of carbohydrate containing liquids (e.g. yoghurt, ice cream, ice pops).

Additional insulin doses should be given every 2 hours until glucose is normal and ketones are less than 0.6mmol/L. If you are on a pump you must give the first correction via a pen injection and then change your pump/cannula. Once confident the pump is re-sited and working illness doses can be delivered manually through the pump.

Contact your GP for general care of the illness. Most medications are sugar free. If not, the amount contained is negligible.

Actions for Ketones and Glucose Levels 10 mmol/L and above - Overview

Ketones <0.6mmol/L

• Glucose 10-14mmol/L = Usual correction dose.
• Glucose 14-22mmol/L = 5% of daily dose OR 0.05 units/kg.
• Glucose > 22mmol/L = 10% of total daily dose OR 0.1 units/kg.

Ketones 0.6-1.5mmol/L

• Glucose 10-14mmol/L = 5% of daily dose OR 0.05 units/kg.
• Glucose > 14mmol/L = 10% of total daily dose OR 0.1 units/kg.

Ketones >1.5mmol/L

• Glucose 10-14mmol/L = 10% of total daily dose OR 0.1 units/kg.
• Glucose > 14mmol/L = 20% of total daily dose OR 0.2 units/kg.

When to call diabetes team or go to hospital

• If your child is vomiting, has abdominal pain, fast breathing, is drowsy, confused or feels cold.
• If ketones remain elevated >1.5mmol/L despite additional insulin and adequate hydration please seek urgent medical advice.
• You are worried about your child.

Ketone Management for Normal Ketones - In Detail

Glucose Level: 10-14mmol/L Blood Ketone Level: Below 0.6mmol/L (normal)

Recommended Actions: 

• Give usual correction dose.
• Check glucose and ketones in 2hrs.
• Have food as usual with insulin.

Glucose Level: 14-22mmol/L Blood Ketone Level: Below 0.6mmol/L (normal)

Recommended Actions: 

• Additional correction dose is needed for high blood glucose level – give 5% of total daily dose OR 0.05units/kg.
• Pump users can deliver the additional insulin via the pump.
• Give sugar free fluids.
• Check glucose and ketones in 2 hours.
• Have food as usual with insulin.

Glucose Level: Above 22mmol/L Blood Ketone Level: Below 0.6mmol/L (normal)

Recommended Actions:

• Additional correction dose is needed for high blood glucose level – give 10% total daily dose OR 0.1 units/kg.
• Pump users can deliver the additional insulin via the pump.
• Give sugar free fluids.
• Check glucose and ketones in 2 hours.
• Have food as usual with insulin.

Ketone Management for Moderate Ketones - In Detail

Glucose Level: 10-14mmol/L Blood Ketone Level: 0.6-1.5mmol/L (moderate)

Recommended Actions: 

• Give extra insulin - give 5% total daily dose OR 0.05 units/kg.
• Pump users to give the additional insulin dose using a pen injection and re-site pump/cannula.
• Check glucose and ketones in 2 hours. Further insulin doses are guided by these levels.
• Give sugar containing fluids.

Glucose Level: Above 14mmol/L Blood Ketone Level: 0.6-1.5mmol/L (moderate)

Recommended Actions: 

• Give extra insulin - give 10% total daily dose OR 0.1 units/kg.
• Pump users to give the additional insulin dose using a pen injection and re-site pump/cannula.
• Check BG and ketones in 2 hours. Further doses are guided by these levels.
• Give sugar free fluids.

Ketone Management for High Ketones - In Detail

Glucose Level: 10-14mmol/L Blood Ketone Level: Above 1.5mmol/L (high)

Recommended Actions: 

Your child is at risk of developing DKA. Watch for signs of abdominal pain, vomiting, drowsiness, confusion or fast breathing. If present take your child immediately to the Emergency Department whilst also following the advice below.

• Give extra insulin immediately - give 10% total daily dose OR 0.1 units/kg.
• Pump users to give the additional insulin dose using a pen injection and re-site pump/cannula.
• Contact the diabetes team urgently.
• Check BG and ketones in 1 hour.
• Encourage sips of sugary fluids with insulin.
• After 2 hours repeat the higher insulin correction dose if ketones have not decreased.

Glucose Level: Above 14mmol/L Blood Ketone Level: Above 1.5mmol/L (high)

Recommended Actions: 

Your child is at risk of developing DKA. Watch for signs of abdominal pain, vomiting, drowsiness, confusion or fast breathing. If present take your child immediately to the Emergency Department whilst also following the advice below.

• Give extra insulin immediately - give 20% total daily dose OR 0.2 units/kg.
• Pump users to give the additional insulin dose using a pen injection and re-site pump/cannula.
• Contact the diabetes team urgently.
• Check BG and ketones in 1 hour.
• Encourage sips of sugar free fluids with insulin.
• After 2 hours repeat the insulin correction dose if ketones have not decreased.

Glucose Level: Glucose may occasionally be near normal but usually high.  Blood Ketone Level: Above 3.0mmol/L (high)

Recommended Actions: 

The ketone level is high. Your child is at high risk of developing DKA. Watch for signs of abdominal pain, vomiting, drowsiness, confusion or fast breathing. If present take your child immediately to the Emergency Department whilst also following the advice below.

• Give extra insulin - give 20% total daily dose OR 0.2 units/kg.
• Pump users to give the additional insulin dose using a pen injection and re-site pump/cannula.
• Contact the diabetes team urgently.
• Check BG and ketones in 1 hour.
• Encourage sips of sugar free fluids with insulin.
• After 2 hours repeat the insulin correction dose if ketones have not decreased.

How to Calculate Ketone Doses

There are different ways to calculate the additional doses advised when ketones are elevated.

1. Based on weight in kg – this can be found at the top of your last clinic letter.

Example:

1. If weight is 50kg and you need to give 0.1 units/kg = 50 x 0.1 = 5 units via pen injection.
2. If weight is 36kg and you need to give 0.05 units/kg = 36 x 0.05 = 1.8 units (suggest rounding up to 2 units for pen injection).

2. Based on total daily dose (TDD) – average insulin required in one day (e.g. long acting insulin (Tresiba or Levemir) dose plus all Novorapid/Fiasp boluses for food and corrections if on injections OR all basal insulin and boluses on a pump. This can be found on your pump/app/Glooko/Carelink upload depending on which system you are using.

Example

1. Injection therapy total is 60 units – 24 units Tresiba & Novorapid 36 units (insulin for breakfast, lunch, tea & supper plus corrections). If needed to give 20% of total daily dose = 60 x 0.2 = 12 units.
2. Pump therapy total daily insulin is 37.2 units - basal (14.7 units) & boluses for meals & corrections (22.5 units). If you needed to give 10% of total daily dose = 37.2 x 0.1 = 3.7 units (suggest rounding to 3.5 units for pen injection).

Worked Example

Your child has developed cough and cold symptoms with a temperature of 38 degrees. Their glucose is 20 mmol/L and ketones are 1.7 mmol/L. Their total daily dose of insulin is 50 units. The amount of fast acting insulin required is 20% of the total daily dose. 

20% of 50 units = 10 units

You would give your child 10 units of fast acting insulin via pen injection and recheck their glucose and ketones in 2 hours. If your child was on a pump, you would change the pump/cannula and check all the equipment was working following pen injection.

2 hours later….

Your child’s temperature has improved and they are feeling a bit better. Their glucose is now 16 and ketones 1.2. You would now give a further correction as ketones are still elevated (this can be delivered via the pump once re-sited). This time the amount of fast acting insulin required is 10% of total daily dose.

10% of 50 units = 5 units

You would give your child 5 units of fast acting insulin and recheck again in 2 hours when the glucose is 9.8 and ketones are 0.5. You can now give your usual correction doses.

J6. Starvation Ketone Recognition and Management

Starvation ketones can be challenging to manage, particularly if your child has diarrhoea and vomiting. They do not usually rise above 1.5mmol/L. Please call the diabetes team early for advice.

Key Points:

• If your child is hypoglycaemic (BG < 3.9) treat appropriately with fast acting glucose and recheck glucose levels after 15 minutes (20 minutes if using a sensor glucose).
• Give extra carbohydrate as food where able otherwise give your child regular sugary fluids with insulin.
• Insulin should not be stopped but it may need reducing. If your child is on a pump the system may well suspend for periods of time to minimise hypoglycaemia.
• Glucose and ketones should be checked every 2 hours (unless ongoing hypoglycaemia where it should be checked and treated every 15-20 minutes until hypoglycaemia has resolved). If you are struggling to keep glucose levels up you may need to come to hospital to have some intravenous fluids containing glucose. The diabetes team can advise on this.

J7: Diabetic Ketoacidosis (DKA)

DKA is a VERY SERIOUS potential complication of diabetes. Ketones are acids and ketoacidosis describes how acidic the blood has become because there is NOT ENOUGH INSULIN in the body. Ketoacidosis can develop within a few hours, especially if you are on an insulin pump and there is an issue with insulin delivery.

DKA can be life threatening. Early recognition and prompt treatment may avoid
hospital admission and the need for intravenous insulin and fluids. Please ring the
diabetes team for advice.

EARLY Signs that your child is developing ketoacidosis:

• Blood glucose level is rising and typically greater than 14 mmol/L with ketones (the higher the ketone level the greater the risk of DKA).
• Confusion.
• Tiredness.
• Increased thirst.
• Becoming dehydrated.

LATE signs that your child has developed or is developing ketoacidosis * Seek Urgent Medical Attention:

• Nausea.
• Vomiting.
• Headache.
• Abdominal pain.
• Breath smells of pear drops (remember not everyone can smell ketones).
• Deep/Sighing breathing.