Blood Ketones
On This Site Tests: Urine Ketones (see Urinalysis - The Chemical Exam); Blood Gases; Glucose Tests Elsewhere On The Web Ask a Laboratory Scientist Your questions will be answered by a laboratory scientist as part of a voluntary service provided by one of our partners, the American Society for Clinical Laboratory Science (ASCLS). Click on the Contact a Scientist button below to be re-directed to the ASCLS site to complete a request form. If your question relates to this web site and not to a specific lab test, please submit it via our Contact Us page instead. Thank you. Continue reading >>
Urine Ketone Dip Test As A Screen For Ketonemia In Diabetic Ketoacidosis And Ketosis In The Emergency Department☆☆☆★★★
Abstract Study objective: To determine the sensitivity of the urine ketone dip test (UKDT) for the detection of ketonemia in patients with diabetic ketoacidosis (DKA) and diabetic ketosis (DK) in the ED. Methods: We conducted a retrospective chart review in the ED of an urban, university- affiliated county teaching hospital. The study population comprised patients seen in the ED during 1994 and 1995 with a discharge diagnosis of DKA or DK and underwent urinalysis within 4 hours of the initial serum electrolyte and ketone determinations. We calculated test sensitivity, along with 95% confidence intervals (CIs). Results: One hundred forty-eight patients with 223 occurrences diagnosed as DKA or DK were seen in the ED during the study period. One hundred fourteen patients with 146 occurrences of DKA or DK met all inclusion criteria; these patients made up the study group. There were 99 cases of DKA and 47 cases of DK. The sensitivity of the UKDT for the detection of ketonemia in all patients with DKA or DK was 97% (95% CI, 94% to 99%) . In the subgroup of patients with DKA, the sensitivity of the UK was 97% (95% CI, 92% to 99%). For patients with DK, the sensitivity of the UK was 98% (95% CI, 89% to 99%). Conclusion: The UKDT is highly sensitive for the presence of serum ketones in patients with DKA and DK. Prospective study is suggested to determine the specificity of the UKDT in this application and to validate its use as a screening tool for the detection of ketonemia in DKA and DK. [Hendey GW, Schwab T, Soliz T: Urine ketone dip test as a screen for ketonemia in diabetic ketoacidosis and ketosis in the emergency department. Ann Emerg Med June 1997; 29:735-738.] Continue reading >>
Diabetic Ketoacidosis Workup
Approach Considerations Diabetic ketoacidosis is typically characterized by hyperglycemia over 250 mg/dL, a bicarbonate level less than 18 mEq/L, and a pH less than 7.30, with ketonemia and ketonuria. While definitions vary, mild DKA can be categorized by a pH level of 7.25-7.3 and a serum bicarbonate level between 15-18 mEq/L; moderate DKA can be categorized by a pH between 7.0-7.24 and a serum bicarbonate level of 10 to less than 15 mEq/L; and severe DKA has a pH less than 7.0 and bicarbonate less than 10 mEq/L. [17] In mild DKA, anion gap is greater than 10 and in moderate or severe DKA the anion gap is greater than 12. These figures differentiate DKA from HHS where blood glucose is greater than 600 mg/dL but pH is greater than 7.3 and serum bicarbonate greater than 15 mEq/L. Laboratory studies for diabetic ketoacidosis (DKA) should be scheduled as follows: Repeat laboratory tests are critical, including potassium, glucose, electrolytes, and, if necessary, phosphorus. Initial workup should include aggressive volume, glucose, and electrolyte management. It is important to be aware that high serum glucose levels may lead to dilutional hyponatremia; high triglyceride levels may lead to factitious low glucose levels; and high levels of ketone bodies may lead to factitious elevation of creatinine levels. Continue reading >>
Diabetic Ketoacidosis
A Preventable Crisis People who have had diabetic ketoacidosis, or DKA, will tell you it’s worse than any flu they’ve ever had, describing an overwhelming feeling of lethargy, unquenchable thirst, and unrelenting vomiting. “It’s sort of like having molasses for blood,” says George. “Everything moves so slow, the mouth can feel so dry, and there is a cloud over your head. Just before diagnosis, when I was in high school, I would get out of a class and go to the bathroom to pee for about 10–12 minutes. Then I would head to the water fountain and begin drinking water for minutes at a time, usually until well after the next class had begun.” George, generally an upbeat person, said that while he has experienced varying degrees of DKA in his 40 years or so of having diabetes, “…at its worst, there is one reprieve from its ill feeling: Unfortunately, that is a coma.” But DKA can be more than a feeling of extreme discomfort, and it can result in more than a coma. “It has the potential to kill,” says Richard Hellman, MD, past president of the American Association of Clinical Endocrinologists. “DKA is a medical emergency. It’s the biggest medical emergency related to diabetes. It’s also the most likely time for a child with diabetes to die.” DKA occurs when there is not enough insulin in the body, resulting in high blood glucose; the person is dehydrated; and too many ketones are present in the bloodstream, making it acidic. The initial insulin deficit is most often caused by the onset of diabetes, by an illness or infection, or by not taking insulin when it is needed. Ketones are your brain’s “second-best fuel,” Hellman says, with glucose being number one. If you don’t have enough glucose in your cells to supply energy to your brain, yo Continue reading >>
Symptoms And Detection Of Ketoacidosis
Symptoms These symptoms are due to the ketone poisoning and should never be ignored. As soon as a person begins to vomit or has difficulty breathing, immediate treatment in an emergency room is required to prevent coma and possible death. Early Signs, Symptoms: Late Signs, Symptoms: very tired and sleepy weakness great thirst frequent urination dry skin and tongue leg cramps fruity odor to the breath* upset stomach* nausea* vomiting* shortness of breath sunken eyeballs very high blood sugars rapid pulse rapid breathing low blood pressure unresponsiveness, coma * these are more specific for ketoacidosis than hyperosmolar syndrome Everyone with diabetes needs to know how to recognize and treat ketoacidosis. Ketones travel from the blood into the urine and can be detected in the urine with ketone test strips available at any pharmacy. Ketone strips should always be kept on hand, but stored in a dry area and replaced as soon as they become outdated. Measurement of Ketones in the urine is very important for diabetics with infections or on insulin pump therapy due to the fact it gives more information than glucose tests alone. Check the urine for ketones whenever a blood sugar reading is 300 mg/dl or higher, if a fruity odor is detected in the breath, if abdominal pain is present, if nausea or vomiting is occurring, or if you are breathing rapidly and short of breath. If a moderate or large amount of ketones are detected on the test strip, ketoacidosis is present and immediate treatment is required. Symptoms for hyperglycemic hyperosmolar syndrome are linked to dehydration rather than acidosis, so a fruity odor to the breath and stomach upset are less likely. How To Detect Ketones During any illness, especially when it is severe and any time the stomach becomes upset, ketone Continue reading >>
Original Article The Value Of Venous Blood Gas Analysis In The Diagnosis Of Diabetic Ketoacidosis
Abstract Newer blood gas analyzers have the ability to report electrolyte values and glucose in addition to pH, so this diagnostic process could be condensed in diagnosing diabetic ketoacidosis (DKA). We aimed to assess the accuracy of the venous blood gas (VBG) analysis with electrolytes for diagnosing DKA. This study prospectively identified a convenience sample of (60 patients) presented with DKA and tested their VBG and serum electrolytes. The diagnosis of DKA was made according to American Diabetes Association criteria. Serum chemistry electrolyte values were considered to be the criterion standard. Sensitivity and specificity of VBG electrolytes results were compared against this standard. In addition, correlation coefficients for individual electrolytes between VBG electrolytes and laboratory chemistry electrolytes were calculated. Paired VBG and serum chemistry panels were available for 60 patients, only 49 patients were included, In this study; 20% of cases were newly diagnosed diabetes mellitus. The total number of diabetic ketoacidosis was 14 patients (28.5%). The sensitivity and specificity of the VBG and electrolytes for diagnosing DKA was 92.9% (95% confidence interval [CI] = 89% to 99%) and 97.1% (95% CI = 92% to 100%), respectively. Correlation coefficients between VBG and serum chemistry were 0.91, 0.47, 0.61, 0.65, and 0.58 for blood sugar, sodium, potassium, chloride, and creatinine respectively. Findings of this study offer preliminary support for the possibility of using VBG sample rather than VBG sample and serum chemistry electrolytes together to rule out diabetic ketoacidosis. Continue reading >>
Blood Gas Measurements In Dka: Are We Searching For A Unicorn?
Introduction Recently there have been numerous publications and discussions about whether VBGs can replace ABGs in DKA. The growing consensus is that VBGs are indeed adequate. Eliminating painful, time-consuming arterial blood draws is a huge step in the right direction. However, the ABG vs. VBG debate overlooks a larger point: neither ABG nor VBG measurements are usually helpful. It is widely recommended to routinely obtain an ABG or VBG, for example by both American and British guidelines. Why? Is it helping our patients, or is it something that we do out of a sense of habit or obligation? Diagnosis of DKA: Blood gas doesn’t help These are the diagnostic criteria for DKA from the America Diabetes Association. They utilize either pH or bicarbonate in a redundant fashion to quantify the severity of acidosis. It is unclear what independent information the pH adds beyond what is provided by the bicarbonate. Practically speaking, the blood gas doesn’t help diagnose DKA. This diagnosis should be based on analysis of the metabolic derangements in the acid-base status (e.g. anion gap, beta-hydroxybutyrate level). The addition of a blood gas to serum chemistries only adds information about the respiratory status, which does not help determine if the patient has ketoacidosis. Management: Does the pH help? It is debatable whether knowing or attempting to directly “treat” the pH is helpful. The pH will often be very low, usually lower than would be expected by looking at the patient. This may induce panic. However, it is actually a useful reminder that acidemia itself doesn't necessarily cause instability (e.g. healthy young rowers may experience lactic acidosis with a pH <7 during athletic exertion; Volianitis 2001). A question often arises regarding whether bicarbonate Continue reading >>
Diabetic Ketoacidosis (dka) - Topic Overview
Diabetic ketoacidosis (DKA) is a life-threatening condition that develops when cells in the body are unable to get the sugar (glucose) they need for energy because there is not enough insulin. When the sugar cannot get into the cells, it stays in the blood. The kidneys filter some of the sugar from the blood and remove it from the body through urine. Because the cells cannot receive sugar for energy, the body begins to break down fat and muscle for energy. When this happens, ketones, or fatty acids, are produced and enter the bloodstream, causing the chemical imbalance (metabolic acidosis) called diabetic ketoacidosis. Ketoacidosis can be caused by not getting enough insulin, having a severe infection or other illness, becoming severely dehydrated, or some combination of these things. It can occur in people who have little or no insulin in their bodies (mostly people with type 1 diabetes but it can happen with type 2 diabetes, especially children) when their blood sugar levels are high. Your blood sugar may be quite high before you notice symptoms, which include: Flushed, hot, dry skin. Feeling thirsty and urinating a lot. Drowsiness or difficulty waking up. Young children may lack interest in their normal activities. Rapid, deep breathing. A strong, fruity breath odor. Loss of appetite, belly pain, and vomiting. Confusion. Laboratory tests, including blood and urine tests, are used to confirm a diagnosis of diabetic ketoacidosis. Tests for ketones are available for home use. Keep some test strips nearby in case your blood sugar level becomes high. When ketoacidosis is severe, it must be treated in the hospital, often in an intensive care unit. Treatment involves giving insulin and fluids through your vein and closely watching certain chemicals in your blood (electrolyt Continue reading >>
Diabetic Ketoacidosis (dka)
Tweet Diabetic ketoacidosis (DKA) is a dangerous complication faced by people with diabetes which happens when the body starts running out of insulin. DKA is most commonly associated with type 1 diabetes, however, people with type 2 diabetes that produce very little of their own insulin may also be affected. Ketoacidosis is a serious short term complication which can result in coma or even death if it is not treated quickly. Read about Diabetes and Ketones What is diabetic ketoacidosis? DKA occurs when the body has insufficient insulin to allow enough glucose to enter cells, and so the body switches to burning fatty acids and producing acidic ketone bodies. A high level of ketone bodies in the blood can cause particularly severe illness. Symptoms of DKA Diabetic ketoacidosis may itself be the symptom of undiagnosed type 1 diabetes. Typical symptoms of diabetic ketoacidosis include: Vomiting Dehydration An unusual smell on the breath –sometimes compared to the smell of pear drops Deep laboured breathing (called kussmaul breathing) or hyperventilation Rapid heartbeat Confusion and disorientation Symptoms of diabetic ketoacidosis usually evolve over a 24 hour period if blood glucose levels become and remain too high (hyperglycemia). Causes and risk factors for diabetic ketoacidosis As noted above, DKA is caused by the body having too little insulin to allow cells to take in glucose for energy. This may happen for a number of reasons including: Having blood glucose levels consistently over 15 mmol/l Missing insulin injections If a fault has developed in your insulin pen or insulin pump As a result of illness or infections High or prolonged levels of stress Excessive alcohol consumption DKA may also occur prior to a diagnosis of type 1 diabetes. Ketoacidosis can occasional Continue reading >>
Diabetic Ketoacidosis And Hyperglycemic Hyperosmolar Syndrome
In Brief Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS) are two acute complications of diabetes that can result in increased morbidity and mortality if not efficiently and effectively treated. Mortality rates are 2–5% for DKA and 15% for HHS, and mortality is usually a consequence of the underlying precipitating cause(s) rather than a result of the metabolic changes of hyperglycemia. Effective standardized treatment protocols, as well as prompt identification and treatment of the precipitating cause, are important factors affecting outcome. The two most common life-threatening complications of diabetes mellitus include diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar syndrome (HHS). Although there are important differences in their pathogenesis, the basic underlying mechanism for both disorders is a reduction in the net effective concentration of circulating insulin coupled with a concomitant elevation of counterregulatory hormones (glucagon, catecholamines, cortisol, and growth hormone). These hyperglycemic emergencies continue to be important causes of morbidity and mortality among patients with diabetes. DKA is reported to be responsible for more than 100,000 hospital admissions per year in the United States1 and accounts for 4–9% of all hospital discharge summaries among patients with diabetes.1 The incidence of HHS is lower than DKA and accounts for <1% of all primary diabetic admissions.1 Most patients with DKA have type 1 diabetes; however, patients with type 2 diabetes are also at risk during the catabolic stress of acute illness.2 Contrary to popular belief, DKA is more common in adults than in children.1 In community-based studies, more than 40% of African-American patients with DKA were >40 years of age and more than 2 Continue reading >>
Measure Electrolyte And Ketone Levels And Determine Anion Gap In Patients With Diabetes And Normal Sugar Levels
DIABETIC KETOACIDOSIS DX: Diabetic Ketoacidosis (DKA) when the blood glucose is >=250 mg/dL, arterial pH <=7.30, serum bicarbonate <=15 mEq/L, and positive serum ketones. (Hyperglycemia, ketonemia, ketonuria, metabolic acidosis) Screening for Diabetic Ketoacidosis - Consider DKA if hyperglycemia, acidosis, or ketonemia are present. Screen all patients with moderate to severely elevated blood sugars (glucose >350 mg/dL). Measure electrolytes, glucose, ketones, and blood gases to determine whether anion gap metabolic acidosis is present in patients with positive ketones, constitutional symptoms, or suspicion of DKA. in patients with an anion gap metabolic acidosis. Measure serum glucose in patients with metabolic acidosis. in diabetes patients with infection, CVA, MI, or other illness. Measure serum glucose and if glucose >250 mg/dL, check the patient's electrolyte and ketone levels and anion gap. in diabetic patients with symptoms of nausea and vomiting (with polyuria, polydipsia), even if blood glucose is <250 mg/dL. if symptoms suggest DKA despite normal blood sugar levels. in patients on atypical antipsychotics who present with hyperglycemia. Measure anion gap and ketones in patients on atypical antipsychotics who present with moderate to severe hyperglycemia. SX: Dehydration with hypotension, hyperventilation with fruity "acetone" odor, polyphagia, polydipsia, polyuria, altered mental status, N&V. History and Physical Examination Elements for Diabetic Ketoacidosis History Type 1 diabetes - DKA is a frequent complication of type 1 diabetes Constitutional symptoms - DKA may show vague symptoms of lethargy, diminished appetite, and headache Polyuria, polydipsia - May precede the development of DKA by 1 or 2 days, especially if intercurrent illness (infection) is present Continue reading >>
Diabetic Ketoacidosis
Initial Evaluation Initial evaluation of patients with DKA includes diagnosis and treatment of precipitating factors (Table 14–18). The most common precipitating factor is infection, followed by noncompliance with insulin therapy.3 While insulin pump therapy has been implicated as a risk factor for DKA in the past, most recent studies show that with proper education and practice using the pump, the frequency of DKA is the same for patients on pump and injection therapy.19 Common causes by frequency Other causes Selected drugs that may contribute to diabetic ketoacidosis Infection, particularly pneumonia, urinary tract infection, and sepsis4 Inadequate insulin treatment or noncompliance4 New-onset diabetes4 Cardiovascular disease, particularly myocardial infarction5 Acanthosis nigricans6 Acromegaly7 Arterial thrombosis, including mesenteric and iliac5 Cerebrovascular accident5 Hemochromatosis8 Hyperthyroidism9 Pancreatitis10 Pregnancy11 Atypical antipsychotic agents12 Corticosteroids13 FK50614 Glucagon15 Interferon16 Sympathomimetic agents including albuterol (Ventolin), dopamine (Intropin), dobutamine (Dobutrex), terbutaline (Bricanyl),17 and ritodrine (Yutopar)18 DIFFERENTIAL DIAGNOSIS Three key features of diabetic acidosis are hyperglycemia, ketosis, and acidosis. The conditions that cause these metabolic abnormalities overlap. The primary differential diagnosis for hyperglycemia is hyperosmolar hyperglycemic state (Table 23,20), which is discussed in the Stoner article21 on page 1723 of this issue. Common problems that produce ketosis include alcoholism and starvation. Metabolic states in which acidosis is predominant include lactic acidosis and ingestion of drugs such as salicylates and methanol. Abdominal pain may be a symptom of ketoacidosis or part of the inci Continue reading >>
How Do You Determine When Is Diabetic Ketoacidosis Serious Enough To Seek Professional Medical Assistance?
If you have DKA, you should seek medical assistance. There is no “safe level.” It is potentially dangerous, and even if you don’t have any immediate perception of damage, over time the acidity of the acidosis can, over time, do a lot of damage to your body. How do you know if you have it? If you have high blood sugar readings and ketones are present in your urine, you should see a doctor as soon as possible. If the amount of ketones is “large”, it is a medical emergency, regardless of how you feel or what other symptoms you have. You test for ketones by using Ketostix. Dip the tip in fresh urine caught for the purpose, The tip will turn colors, indicating the presence of urine. The color will indicate the amount of ketones, with the most intense colors meaning the highest levels. Check the expiration date on the Ketostix. If you do not test for ketones frequently, they may expire before they are used up and you should not rely on them. They may be better than nothing if that is all you have. As a diabetic or the caregiver of a diabetic, you should have Ketostix on hand. The doctor can tell you at what blood sugar reading you should check for ketones. It might be something like above 300, which means that whenever you get a reading of 300 or above, you should check for ketones. Ketones cause the urine to have an identifiable smell often described as fruity or acetone-like. If you can smell that, your level of ketones is high enough that you should see a doctor, regardless of whether you have any Ketostix. Wikipedia has an article about diabetic ketoacidosis. Continue reading >>
Understanding Diabetic Ketoacidosis Lab Values
Diabetes can be a difficult condition to monitor. You need to consistently eat right and be aware of even slight changes concerning how you’re feeling physically… especially when there are really scary things that can happen, like diabetic ketoacidosis (DKA). When your cells don’t get the sugar they need to make into energy, your body then starts to burn fat for energy, which produces ketones. This happens when your body doesn’t have enough of the hormone insulin to turn the glucose (sugar) into energy. Excess ketones can be extremely dangerous when they build up in the blood because they can make the blood too acidic. Acidic blood is toxic to your cells and can impair them so they can’t function properly. This causes them to have a hard time fighting bacterias and viruses and they also won’t be able to process the oxygen and nutrients in your blood properly, depleting you of energy. If you’re not careful, this condition could be fatal. Warning Signs of DKA DKA usually occurs over several hours and there are variety of warning signs that you should be aware of to prevent this condition from becoming dangerous. Here are a few symptoms to watch for: Extreme dry mouth or thirst Dry or flushed skin Always feeling tired Difficulty breathing Your breath smells sweet or fruity Confusion or having a hard time paying attention How to Test for DKA If you have diabetes, you should consider buying at home ketone tests to ensure that your blood levels are in the appropriate range at all times. For example, Amazon.com has a variety of easy-to-use tests that are extremely inexpensive. If you are feeling any of the above symptoms, you can simply use a urine sample to know if you are within healthy ketone limits. The test pad will change colors and you can match your test Continue reading >>
Diabetic Ketoacidosis And Hyperosmolar Hyperglycemic State In Adults: Clinical Features, Evaluation, And Diagnosis
INTRODUCTION Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS, also known as hyperosmotic hyperglycemic nonketotic state [HHNK]) are two of the most serious acute complications of diabetes. DKA is characterized by ketoacidosis and hyperglycemia, while HHS usually has more severe hyperglycemia but no ketoacidosis (table 1). Each represents an extreme in the spectrum of hyperglycemia. The precipitating factors, clinical features, evaluation, and diagnosis of DKA and HHS in adults will be reviewed here. The epidemiology, pathogenesis, and treatment of these disorders are discussed separately. DKA in children is also reviewed separately. (See "Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Epidemiology and pathogenesis".) Continue reading >>
