Pink Panther - Diabetes Management - Chapter 15

TOPIC:Prevent, Detectand Treat AcuteComplications(Ketones andAcidosis)TEACHING OBJECTIVES:1. Describe causes of ketone

production.2. Present signs and symptoms of

having ketones.3. Discuss treatment plan for

preventing or eliminatingketones.

LEARNING OBJECTIVES:Learner (parents, child, relative orself) will be able to:1. List two causes of ketones.2. Describe two symptoms of

having ketones.3. Explain two methods to

prevent or eliminate ketones.

Chapter 15

Ketones and Acidosis

CAUSES OF KETONES AND ACIDOSISOne emergency in diabetes, low blood sugar

(hypoglycemia), was discussed in Chapter 6. The otheremergency is the build-up of ketones in the blood or urine,which can develop into acidosis. Acidosis is most commonwith type 1 diabetes, but it can also occur with type 2 diabetes.The measurement of urine or blood ketones is very easy andwas discussed in Chapter 5.

When people are referred to our Center, the most commonknowledge deficits are:

4 the dangers/meaning of ketone build-up

4 when to test for ketones

4 not having the supplies in their home to test for ketones

4 not knowing what to do when ketones are present

These deficits can result in a serious episode of acidosis.

Large urine or blood ketones are usually present for atleast four hours before the total bodys acidity is increased(acidosis or DKA). Acidosis is very dangerous and people cango into a coma or die from it. It is the cause of 85 percent ofhospitalizations of children with known diabetes. The goodnews is that it is 98 percent preventable if people follow theinstructions in this chapter. Acidosis can be prevented in aperson who is known to have diabetes.

Ketones and acidosis are due to not enough insulin beingavailable to meet the bodys needs.

The five main causes are:

1. Illnesses/infections: extra energy may be needed by thebody. This cannot be made unless extra insulin is available

163

164 Chapter 15 Ketones and Acidosis

to make the extra energy from sugar.

2. Forgetting to take an insulin shot: insulin isnot available to the body.

3. A lack of insulin (see Table 1): this couldhappen in a person coming out of thehoneymoon period who has not hadinsulin dosages increased.

4. Traumatic stresses on the body (particularlywith type 2 diabetes): people with type 2diabetes sometimes get ketones during anillness. However, other body stressors suchas surgery or a heart attack may result inketone production.

5. A pump insertion coming out or notfunctioning (Chapter 26): As pumps userapid-acting insulins, there will be nofurther insulin activity 3-4 hours after aninsertion malfunctions.

Remember the statement from Chapter 2:

I MUST TAKE MY INSULIN/ORALMEDICATION EVERY DAY FROMNOW ON. IF I FORGET MYINSULIN/ORAL MEDICATION, MYDIABETES WILL GET OUT OFCONTROL. THERE ISABSOLUTELY NO WAY I WILL NOTNEED INSULIN/ORALMEDICATION EVERY DAY FROMNOW ON.

Table 1Main Causes of Acidosis

Infection

Missed insulin injections

Not enough insulin

Traumatic stress on the body(particularly type 2 diabetes)

A pump insertion coming out ornot functioning (Chapter 26)

Table 2Main Functions of Insulin

To allow sugar to pass into cellswhere it can be used for energy

To turn off excess production ofsugar in the liver

To turn off fat breakdown

Chapter 15 Ketones and Acidosis 165

Insulin is needed to (see Table 2):

1. allow sugar to pass into cells

2. turn off the bodys machinery for makingsugar

3. turn off fat breakdown in order to stopketone production

The blood sugar is usually high with largeketones and acidosis because the second andthird functions of insulin are not happening.This is because not enough insulin is available.The stress hormones are also high withillnesses/infections. These hormones act toincrease blood sugar and ketone production.The high blood sugar causes sugar to pass intothe urine (see Chapter 2) and the person mustgo to the bathroom a lot (frequent urination).The body may lose too much water and becometoo dry (dehydration). The tongue may feeldry and furry. Drinking lots of fluids may helpprevent this. The main treatment, however, istaking extra insulin to shut off the bodysmachinery for making sugar and ketones.

It is not high blood sugar that causesketones or acidosis. In fact, eating sugar doesnot cause acidosis. Ketones come from thebreakdown of body fat (see picture at the end ofthis chapter). The third role of insulin (seeTable 2) is to shut off fat breakdown. Fatbegins to break down because not enoughinsulin is available and stress hormones are high.The side-product of fat breakdown is ketoneproduction. Ketones are initially passed into theurine (ketonuria). They may start with trace orsmall levels and gradually build up to moderateand large levels. They also gradually build up inthe blood. Once they reach the large level, theymay start to build up in the body tissues. Theyare easier to reverse if treated early. The longersomeone has large ketones, the more likely theywill build up in the body resulting in acidosis(DKA). Thus, the early detection and reversalby giving extra insulin is critical.

There are several reasons why fat is brokendown:

l Not enough insulin is available to help thecells burn the needed sugar.

l The body needs more energy (e.g., forillness/infections) and the fat is brokendown to provide this energy.

l The stress hormones; steroids, adrenaline(epinephrine) and glucagon have beenreleased, causing fat breakdown.

l Sugar is not available due to vomiting ornot eating and fat is broken down for theenergy needed. Anytime fat is broken downfor energy, ketones are formed.

SYMPTOMS OF ACIDOSISIn any of the above cases, fat is broken

down. The ketones are made from the fat.Acidosis usually comes on slowly, over severalhours, and has the following symptoms:

4 Upset stomach and/or stomach pain

4 Vomiting

4 Sweet (fruity) odor to the breath

4 Thirst and frequent urination (if the bloodsugar is high)

4 Dry mouth

4 Drowsiness

4 Deep breathing (indicates need to go toemergency room)

4 If not treated, coma (loss of consciousness)

On occasion, it may be difficult to know if aperson is having difficulty with low blood sugaror with acidosis. Testing the blood sugar andketones will help identify the correct problem.Table 3 may also be helpful in thinking aboutthe two problems.


Tab

le3

The

Two

Em

erge

ncie

sof

Dia

bete

sL

owB

lood

Suga

r(C

hapt

er6)

Ket

oaci

dosi

s(C

hapt

er15

)(H

ypog

lyce

mia

orIn

sulin

Rea

ctio

n)(A

cido

sis

orD

KA

)

Due

to:

Low

bloo

dsu

gar

Pres

ence

ofke

tone

s

Tim

eof

onse

t:Fa

st

with

inse

cond

sSl

ow

inho

urs

orda

ys

Cau

ses:

Too

little

food

Too

little

insu

linT

oom

uch

insu

linN

otgi

ving

insu

linT

oom

uch

exer

cise

with

out

food

Infe

ctio

ns/

Illn

ess

Mis

sing

orbe

ing

late

for

mea

ls/

snac

ksT

raum

atic

body

stre

ssE

xcite

men

tin

youn

gch

ildre

nPu

mp

inse

rtio

nsm

alfu

nctio

ning

Blo

odsu

gar:

Low

(bel

ow60

mg/

dlor

3.3

mm

ol/

L)

Usu

ally

high

(ove

r24

0m

g/dl

or13

.3m

mol

/L

)

Ket

ones

:U

sual

lyno

nein

the

urin

eor

bloo

dU

sual

lym

oder

ate/

larg

ein

the

urin

eor

bloo

dke

tone

sov

er0.

6m

mol

/L

.

SYM

PT

OM

ST

RE

AT

ME

NT

SYM

PT

OM

ST

RE

AT

ME

NT

Mild

:H

unge

r,sh

aky,

Giv

eju

ice

orm

ilk.

Thi

rst,

freq

uent

urin

atio

n,G

ive

lots

offlu

ids

and

swea

ty,n

ervo

usW

ait

10m

inut

esan

dsw

eet

brea

th,s

mal

lor

mod

erat

eH

umal

og/

Nov

oLog

/A

pidr

ath

engi

veso

lidfo

od.

urin

eke

tone

sor

bloo

dke

tone

sor

Reg

ular

insu

linev

ery

two

less

than

1.0

mm

ol/

L.

orth

ree

hour

s.

Mod

erat

e:H

eada

che,

unex

pect

edG

ive

inst

ant

gluc

ose

Dry

mou

th,n

ause

a,st

omac

hC

ontin

ued

cont

act

with

heal

thca

rebe

havi

orch

ange

s,or

afa

st-a

ctin

gcr

amps

,vom

iting

,mod

erat

epr

ovid

er.

Giv

elo

tsof

fluid

s.G

ive

impa

ired

ordo

uble

suga

r,ju

ice

oror

larg

eur

ine

keto

nes

orH

umal

og/

Nov

oLog

/A

pidr

aor

visi

on,c

onfu

sion

,su

gar

pop

(4oz

).bl

ood

keto

nes

betw

een

Reg

ular

insu

linev

ery

two

orth

ree

drow

sine

ss,w

eakn

ess

Aft

er10

min

utes

,1.

0an

d3.

0m

mol

/L

.ho

urs.

Giv

ePh

ener

gan

med

icat

ion

ordi

ffic

ulty

talk

ing.

give

solid

food

.(s

uppo

sito

ryor

topi

calc

ream

)if

vom

iting

occu

rs.

Seve

re:

Los

sof

cons

ciou

snes

sG

ive

gluc

agon

into

Lab

ored

deep

brea

thin

g,G

oto

the

emer

gen

cyro

om.

orse

izur

es.

mus

cle

orfa

t.ex

trem

ew

eakn

ess,

conf

usio

nM

ayne

edin

trav

enou

sflu

ids

Tes

tbl

ood

suga

r.an

dev

entu

ally

unco

nsci

ousn

ess

and

insu

lin.

Ifno

resp

onse

,cal

l(c

oma)

:la

rge

urin

eke

tone

spa

ram

edic

(911

)or

goor

bloo

dke

tone

sab

ove

toE

.R.

3.0

mm

ol/

L.


PREVENTION OF ACIDOSISAcidosis is the cause of 85 percent of re-

admissions to the hospital for someone withknown diabetes. Most of these admissionscould be prevented if the problem wereidentified and treated earlier. The simple rulesoutlined in Table 4 will prevent most cases ofacidosis. It is a good idea to review this chapterevery year. Families may forget the importanceof checking urine or blood ketones during anyillness. Some people with diabetes who stillmake some of their own insulin, or who are invery good diabetes control, will have themachinery (enzymes) for making the ketonesremain turned off. As a result, they may goseveral years and never have urine or bloodketones with an illness. As they grow older anda few more islet cells are lost, or they outgrowtheir remaining islets, they may suddenly findketones present.

The important message is always toremember to check for ketones anytime aperson with diabetes is ill. You must also checkfor ketones anytime the blood sugar is above 240mg/dl (13.3 mmol/L) fasting or above 300mg/dl (16.7 mmol/L) during the day.

The prevention of acidosis is based on beingable to detect changes early. Knowing whenketones are forming in the urine or blood, butbefore the ketones build up in the body, isimportant.

Preventing acidosis the person with diabetes/orthe family:

4 must have a method in the home to checkurine or blood ketones (see Chapter 5)

4 must remember to check for urine or bloodketones anytime the person is sick (evenwith vomiting only one time)

4 needs to check ketones if the blood sugar ishigh

4 should call the diabetes care providerimmediately (night or day) if moderate orlarge urine ketones or blood ketones > 1.0mmol/L are present

4 needs to give extra rapid-acting insulin(Humalog/NovoLog) every two hours orRegular insulin every three hours until theurine or blood ketones have decreased

4 must drink lots of fluids to wash the ketonesout of the body and to prevent dehydration

A low blood sugar can sometimes bepresent with acidosis, and so urine ketonesmust be checked with every illness, even ifthe blood sugar is low. A summary of theinstructions is in Table 4.

Extra Insulin

When ketone production becomes totalbody acidosis, it is usually because the largeamount of ketones has been present for four to12 hours. This can happen because the urine orblood ketones have not been checked or noextra insulin has been given. Insulin shuts offketone production. Extra insulin must be givenif someone has moderate or large urine ketonesor blood ketones above 0.6 mmol/L. The doseof extra insulin varies for different people, andthe diabetes care provider can help decide on asafe dose.

General Guidelines When Giving ExtraInsulin

The blood sugar should be checked beforeeach insulin injection.

For moderate urine ketones or bloodketones between 0.6 and 1.5 mmol/L:

The extra dose is usually in the range of 5-10 percent of the total daily dose (seeTable 5). The extra dose is given asHumalog/NovoLog/Apidra every twohours or Regular insulin every three hours.

For large urine ketones or blood ketonesabove 1.5 mmol/L:

The dose of extra insulin is usually 10-20percent of the total daily dose. This extrainsulin is given as Humalog/NovoLog/Apidra every two hours or Regular insulingiven every three hours.


Table 5 outlines a possible treatmentschedule.

The extra insulin may seem like a large dose,but ketones block the normal sensitivity ofthe body to insulin. Although every personis different, dosages in these ranges areusually needed.

If the blood sugar drops below 150 mg/dl(8.3 mmol/L), it may be necessary to sipregular sugar pop, juice or other sugareddrinks. This is done to bring the bloodsugar back up before giving the next insulininjection.

Remember, the extra insulin and fluids arebeing given to clear the urine or blood ketones.

Extra Fluids

In addition to taking extra insulin, drinkingfluids (e.g., water and fruit juices) is importantin the prevention of acidosis. These liquidsreplace the fluid lost in the urine and helpprevent dehydration. The juices also replacesome of the salts that are lost in the urine.Orange juice and bananas are particularly goodfor replacing the potassium that is lost. Asdiscussed in the next chapter (Sick-dayManagement), a medication called Phenergan issometimes used if vomiting is a problem.

When severe acidosis has been present formany hours, coma (loss of consciousness) canfollow. This is dangerous. It is much better to

Table 4Prevention of Ketoacidosis

Remember to check urine or blood ketones withany illness (even an upset stomach or vomitingone time) or anytime the fasting blood sugar isabove 240 mg/dl (13.3 mmol/L) or a daytimeblood sugar is above 300 mg/dl (16.7mmol/L).

Call the diabetes care provider immediately(night or day) if moderate or large urine ketonesor blood ketones above 1.0 mmol/L are found.

Take extra insulin (after checking the bloodsugar and urine or blood ketones). TakeHumalog/NovoLog/Apidra every two hours, orRegular insulin every three hours, until the urineketones are small or less or the blood ketones arebelow 0.6 mmol/L.

If the blood sugar falls below 150 mg/dl (8.3mmol/L) and urine or blood ketones are stillpresent, drink juice (preferably orange as itreplaces potassium), Pedialyte or sugared pop(soda) to keep the blood sugar up so that moreinsulin can be given to turn off the ketoneproduction.

Drink lots of fluids to help wash out the ketones.


prevent severe acidosis than to have to treat itwith IV fluids and a hospital admission. Thehospital admission is usually in an intensive careunit, which is scary for everyone. Intravenouslines are usually put in both arms (andsometimes the feet). A constant heart-monitoring machine is attached to the person.The cost is about $10,000.

Preventing acidosis is generally possiblewhen the rules in Table 4 are followed.Ketoacidosis in patients with known diabetesrarely occurs in people who attend clinicregularly. When it does occur, it is usuallybecause the directions in Table 4 were notfollowed.

DEFINITIONSAcetone: One of the ketones which builds upin the urine, blood and body during acidosis. Itis sometimes used (incorrectly) to refer to allketones.

Acidosis (diabetic ketoacidosis or DKA):What happens in the body when not enoughinsulin is available. Blood sugar is usually high

at this time. Moderate or large ketones arepresent in the urine or blood and then build upin the body. The ketones make the body fluidsmore acidic resulting in total body acidosis.

Beta hydroxybutyrate (-OH butyrate): The most important of the three main ketones(along with acetone and acetoacetic acid). It isthe ketone that is measured in the blood ketone test.

Dehydration: Loss of the body fluids. Thetongue and skin are usually very dry and theeyes look sunken. Babies have less than half theusual number of wet diapers.

Ketones: Fat breakdown products that initiallyspill into the urine and later build up in theblood when there is not enough insulin. Manypeople can smell a sweet odor on the breath.The fat breakdown products cause acidosis (orketoacidosis).

Potassium: One of the salts (along withsodium) lost in the urine when ketones arespilled in the urine. Orange juice and bananascontain a lot of potassium and are best to give ifurine ketones are present.

Table 5Ketone Levels* in Blood or Urine and a Suggested Dose of Rapid-Acting or Regular Insulin

Dose of H/NL/AP every 2 hours orUrine Blood (mmol/L) Dose of Regular every 3 hours

Trace/Small < 0.6 per correction factor for blood sugar

Moderate - 0.6 1.5 10% of total daily insulin dose**Large

Large - > 1.5 20% of total daily insulin dose**Very Large

* The blood and urine ketone results do not agree exactly and the above correlations are estimates. Theblood ketone result reflects the ketone level at the exact time the test is done. If the urine has been inthe bladder for some time, then the urine ketone result may not tell the current status.

** The total daily insulin dose is the sum of all insulin taken in a 24-hour period (rapid-acting plusintermediate-acting plus long-acting).


QUESTIONS AND ANSWERSFROM NEWSNOTES

Please explain what ketoacidosis(acidosis) is and how it can beprevented.

Acidosis is one of the two emergencyproblems of diabetes (low blood sugarbeing the other). It is the main cause

of children with known diabetes being admittedto the hospital. It is responsible for 85 percentof hospitalizations. Most of thesehospitalizations can be prevented with goodfamily education and with followinginstructions.

Families can check for ketones at home withurine or blood. If using urine Ketostix, use thefoil-wrapped strips. The bottles of strips expiresix months after they have been opened.Checking for ketones should be done ANYTIME THE PERSON IS FEELING ILL.Also, check ketones if the blood sugar is above240 mg/dl (13.3 mmol/L) fasting or above300 mg/dl (16.7 mmol/L) during the day. Ifmoderate/large urine ketones are found orblood ketones are above 1.0 mmol/L, thehealthcare provider should be calledimmediately. Calling the healthcare providermay be necessary every 2-3 hours for dosages ofHumalog/NovoLog/Apidra or Regular insulin.After the ketones have decreased to smallamounts or have gone away, the extra injectionscan be stopped.

On any given day, five to 10 children arebeing treated for ketonuria by phone by theBarbara Davis Center staff. This happensespecially during the flu season. Fortunately,hospital admissions have gone downdramatically as a result of this treatment and arenow infrequent.

The cause of ketone production is thebodys need for energy. Sometimes, the bodyneeds extra energy (e.g., during an illness).Because there is not enough insulin or sugaravailable to use sugar for energy, the fat tissueresponds by releasing fats. These fats are then

broken down. Some of these fats are made intoketones by the liver. As the ketones build upfollowing the fat breakdown, ketoacidosiseventually results. The most frequentsymptoms are a stomachache and, eventually,vomiting. Deep breathing is a late sign andindicates a need to go to an emergency room.

Why does someone feel sick whenthe ketones are moderate or large in the urine or > 0.6 mmol/L in

the blood?

There are at least three parts to theanswer to this question:

1. The bodys acid-base (pH) balance is finelytuned (a bit on the basic side at 7.35-7.45).Acids and bases are difficult to explain.Examples of a base and an acid are: soap isan alkaline (base) material and tomatoes areacidic. Ketones (which are acids) make thebody fluids more acidic as they start to buildup. As the body becomes more acidic,many of the bodys functions can no longerwork as they should. If left untreated, deathwill eventually follow.

2. The second reason a person feels ill isbecause of a potassium and sodiumimbalance. They are important body salts,and are lost with ketones going out in theurine. Potassium is important for themovement of the intestine (moving foodthrough). If too much potassium is lost,this movement decreases or stops. Whenthis happens, an upset stomach andvomiting can occur. We often recommendorange juice (high in potassium) and applejuice in addition to water when someonehas urine or blood ketones. Drinking lotsof liquids helps to keep good hydration andto flush out the ketones.

3. Poor hydration would be the third reason forfeeling ill. Usually, frequent urination due tohigh blood and urine sugar happens togetherwith urine ketones. This can lead to

QA

Q

A


dehydration. Our bodies are 60 percentwater. If even 10 percent of body weight islost as water, it is possible to be very sick.Fluids can also be lost in large amounts withthe flu (vomiting and diarrhea). If fluid isbeing lost in large amounts from both thekidneys (frequent urination) and fromvomiting and/or diarrhea, dehydration canoccur even more rapidly. Children under theage of five can become dehydrated in less thanfour hours. They are more likely to requireIV treatment sooner than older children.

What is cerebral edema and howdoes it relate to diabeticketoacidosis (DKA)?

Cerebral edema refers to swelling ofthe brain, which is a rare complicationof treating DKA. The cause is not

fully understood and when it does occur, it isoften fatal.

Perhaps we have been lucky. In 25 yearssince the Center opened, and over 30 years ofworking with children with diabetes, I haveseen only two or three cases of cerebral edemain children who had been previously diagnosedwith diabetes. Part of the reason it is so rarerelates to the now relative infrequency of DKA.Our families are asked to check urine or bloodketones with every illness. They are asked tocall when urine ketones are moderate or large

or the blood ketone level is > 1.0 mmol/L.Extra shots of Humalog/NovoLog/Apidra orRegular insulin are then given to reverse theketones before DKA occurs. In one period wehad only six cases of DKA among 1,200 familiesin 12 months! Stopping ketone formation earlyreduces the likelihood of a case of DKAresulting in cerebral edema. It is better toprevent DKA than to deal with its bad effects.Unfortunately, cerebral edema is more commonin newly diagnosed children when the ketoneshave built up over a longer time period.

Our son has had diabetes for overtwo years. Every time he has gottensick we have checked for urine

ketones. The results have always beennegative or trace. Can we stop checking now?

The answer is NO! This is often thecase for someone who still makes someof their own insulin and/or someone

who is in excellent sugar control. The machinery(enzymes) for making ketones from fat are socompletely turned off that they dont get turnedon by the illness. Unfortunately, as your sonsinsulin production declines or he outgrows hisremaining insulin production, he will probablysuddenly have ketones with an illness. One neverknows when this will occur. Thus, the onlyanswer is to keep checking the urine ketones atleast twice each day with each illness.

Q

AQ

A


Diabetes

No Insulin

Sugar becomes high in the blood. Sugarspills into urine. Frequent urination will

result in loss of body fluids or dehydration.Sugar cant be used, resulting in fat

breakdown as an energy source.

No Energ y

Normal

Insulin

Energ y

Fat

Fat breakdown results in:

1. Weight loss

2. Ketones, which are a breakdown product offat and appear in the blood and urine

3. Too many ketones in the body = acidosis

Date post:	05-Nov-2015
Category:	Documents
Upload:	jennmoyer
View:	215 times
Download:	0 times

Pink Panther - Diabetes Management - Chapter 15

Documents