How high do you let ketones get before heading to the ER?

[BrendaK]

Well, the dreaded stomach flu came today. Carson threw up just once after school, but it was bad. No fever, lower blood sugar, and blood ketones are at 1.4 right now. Our endo is very conservative and says if they don't pee every hour then you need to come in. Well, I'm not quite THAT anxious to come in.

So how long do you wait? And how high should I let ketones get?

He's eating a popsicle right now. We did the mini glucagon 2 hours ago. It works great -- he's at 85 right now and if he can't/won't eat the popsicle, I'll do the mini glucagon again.

I'm waiting for DH to get home from work with regular sprite and gatorade. He says he'll drink that.

We just moved 2 1/2 months ago and have a great hospital 3 blocks away. I really don't want to visit it yet....

Oh good -- he says he just ate the popsicle...

[Nancy in VA]

I would wait until I was sure I couldn't flush them.

If you can get sugar into him, then pump him full of insulin to clear them out. Be careful of using the mini-glucagon too often - your liver only has a finite supply of glucose and if you use it too often, it doesn't have time to replenish.

We woke up with ketones at 3.1 in October. And she was LOW. We had to really carb-load her in order to give her enough insulin. But, the insulin cleared them pretty easily.

[Debbie]

I always wait until the doctor practically forces me to take her to the ER. If he's eating and the mini-glucagon is working and you can give him insulin to help get rid of the ketones you should be alright. Last time I ended up taking DD to the ER, I think I waited too long. It took her a really long time to get better. The doctor was ready to run tests for other diseases. It was very scarey---I guess sometimes it's a fine line on how long to handle it on your own.

I hope he feels better soon and that no one else gets it!

[luvmytwins02]

We are going through this now too. So far her ketones haven't gone above .8. I was told that anything above 1.5 needed to be taken seriously and to call their endo. What is the mini glucagon that you are talking about?

I just learned last year during the stomach flu what glucagon really was. I thought it was a sugar shot, but I learned it actually releases your sugar reserves, so you really can't use it too many times because there are only so many reserves to go around.

[BrendaK]

Glucagon can be given in "mini" doses for times when kids have the stomach flu and can't eat and they are low. Here's a link http://www.childrenwithdiabetes.com/d_0j_20w.htm. Basically it's 1 unit per year of age every 2 hours. We've used this very cautiously and with good sucess one or two other times. (I wouldn't give it to him all night long, we'd be in the ER by then!) But I had to do something because he was at 57 and couldn't eat at all (that was right before the big throw up).

I just looked at the new box of ketone strips and 1.9 -2.9 is moderate with this box. He's at 1.8 right now with a bs of 148. Hopefully he'll drink some Sprite when DH gets home hopefully within the hour and I can give some insulin. (His holiday work party was today and it was FAR from our house :()

He ate 1/2 of another popsicle, but I just read the carb info and there are only 6 carbs in those flavor ice things. Darn.... I wish there were more!

I try to keep sprite and gatorade on hand at home, but I quit restocking it after DH kept taking it to work in his lunch!!!

Carson hasn't thrown up in 2 1/2 years -- we just don't deal with ketones hardly ever!!

I'm going to wait it out until bedtime tonight and see how it goes.

[Mama Belle]

It really is a fine line Brenda. I would say that as long as he can keep down something with sugar (popsicles, sprite, gingerale) to get those BGs up high enough to give insulin, you can stay home. However, if the sugary drinks won't raise BG enough to give insulin, or he can't hold it down and his ketones continue to rise, then you better pack for the ER. You don't want ketones to get so bad that it causes vomiting (that is a vicious cycle that is very hard to break).

When Sam had influenza 2 years ago she ran ketones all day and they finally cleared in the evening before bed. We did not need to go to the ER because she had high BGs so we were dosing her with insulin almost constantly. BUT, the last time she had the stomach flu badly, her ketones rose very quickly and eventually ended up causing vomiting. At that point she could not keep anything down and her BG was in the 60s, mini-dose glucagon did nothing, her reserves were shot at that point. So just make sure that ketones don't rise too much too quickly. Also, the sooner you can get sugar pop in him the better he'll be. Tell you hubby to be quick!

[Mary Lou]

I think the situation is more dynamic than just a hard number as to when to go.

If ketones are increasing, and you are unable to flush them, if the child is throwing up and/or losing fluids to the point of dehyration, then you need to go.

If I were you (and now I"ve gone through this 4 times this season), I'd call your endo for instructions. We were advised to decrease basal by 50% and to only bolus for 50% of carbs consummed, but to make sure that carbs are being consumed. If there's a choice betwen eating and drinking -- DRINK, and drink sugared drinks (regular gingerale, vitamin water, gatorade, whatever).

Monitor BG hourly, ketones every 1.5 - 2 hours and watch for increases. Remember that ketones can appear and grow with normal and low BGs.

I'd stay home until I had to go, but having just gone on Monday (for the first time), I think we should've gone a little sooner. At the point we left home, Andrew's ketones were 2.2, but were 3.5 at the ER. He jumped from 0.8 to 2.2 in a matter of a couple hours.

BTW -- our literature from Children's Boston says: 0.0 - 0.5 mmol/L is normal; 0.6 - 1.5 is moderate; 1.6 - 3.0 is "significantly increased blood ketone level, patient is at risk for DKA; >3.0 is consistent with metabolic acidosis.

[BrendaK]

I am amazed at how fast ketones can come and go!!

I think we're going to be okay. Before DH got home he was up to 189 and I gave him 2 glucotabs and bolused for it -- I had to get some insulin in him somehow!!

Then DH came home w/the regular sprite and Carson just finished a whole cup of it. So I bolused for that, too. Ketones are down to 1.1 now (they were up to 1.8 an hour or so ago). With the insulin and soda in his system I hope we're okay. He says he feels much better now.

Since we just moved, we're still waiting to get into a new endo. We've had our records transferred, but haven't had an actual appointment yet. Same with the pediatritian. Records are transferred, but a new patient appointment isn't for 3 more weeks. So we don't have a doctor out here yet!!! I'm sure our old endo would have taken questions over the phone from an ER, but it was just another reason I didn't want to go if it wasn't necessary.

Mary Lou -- my old ketones numbers were more in line with what you wrote, but I think the new precision Xtra test strips may be different -- I had a hard time finding what moderate/large numbers were but on the insert it gave 1.9-2.9 for moderate with that "lot number."

[BrendaK]

I think we're in the clear. Ketones are down to 0.3, blood sugar is 247, so I'll wait and check it again in a couple of hours and bolus if necessary.

Carson feels great now. I'm keeping him home from school tomorrow, but he seems completely fine now.

Yeah, we made it through without the ER. Thanks for all the support and advice!!

The 4 year old had the same thing last Thursday -- I'm surprised it took so long for Carson to get it. Now DH doesn't feel well....At least it's before Christmas and hopefully we'll all be well by then!

[Kaylee's Mommy]

glad his bg is up and ketones down.. Kaylee's endo starts to worry about anything over 1.0.. the end of last week she had a nasty cold and ketones at 1.5/1.9 and her CDE was very concerned.. i was check ketones every time I checked bg.. they'd come down but head right back up.. and fast too.. if you can keep them down and avoid the ER that would be the best thing, obviously..

I hope he's feeling a lot better soon and you can avoid the ER all together..

[Lee]

Glad he is feeling so much better! Getting those ketones down can also help settle his tummy!

[Mary Lou]

Mary Lou -- my old ketones numbers were more in line with what you wrote, but I think the new precision Xtra test strips may be different -- I had a hard time finding what moderate/large numbers were but on the insert it gave 1.9-2.9 for moderate with that "lot number."

I wonder if it's a pediatric thing vs an adult thing? Just a thought...