View Full Version : blood ketone tests and starvation ketones
I seem to remember reading here once that when measuring ketones with the blood meter it will not measure starvation ketones. Does anyone know if this is true? And if so, can you point me to something "official" that says it? I have tried searching and have been unsucessful.
Thanks a lot.
Lynn
I seem to remember reading here once that when measuring ketones with the blood meter it will not measure starvation ketones. Does anyone know if this is true? And if so, can you point me to something "official" that says it? I have tried searching and have been unsucessful.
Thanks a lot.
Lynn
I think ketones are ketones, and I can't imagine that the meter distinguishes between them. But I'm not sure I've seen "official" confirmation of that. This may be a question to direct to the company producing the meter.
Given that ketones can be produced in 3 different types of situations (lack of insulin in bloodstream, lack of food, or burning fat in heavy physical activities) it would be worth getting a definitive answer to this great question.
Nancy in VA
11-13-2007, 08:51 AM
We had starvation ketones when Emma was sick a few weeks ago. She had insulin in her system, so they weren't insulin-lacking ketones and our meter picked them up.
A ketone is a ketone. Starvation vs. lack of insulin is just the reason they start, but they develop from there the same.
In my quest to find the answer to this question, I learned that a ketone isn't necessarily a ketone. What I mean by this is that there are three different types of ketones.
They are actually different--not JUST caused by different things going on in the body.
Maybe I am crazy and I didn't read that here.
Lynn
Mary Lou
11-13-2007, 09:57 AM
That's really interesting!!
We recently went through a period of illness that involved starvation ketones and they registered with both the urine strips and the Precision Extra Ketone Meter.
I know that's not "official", but it's what I got :cwds:
EmmasMom
11-13-2007, 10:40 AM
An important thing to remember is that all ketones are from "starvation" in your body and high levels should always be taken very seriously. There are not different ketones for different circumstances, (fever, dieting, vomiting), they all cause the same ketones, but Beta-Hydroxybutyrate is the most important of three ketones in the blood. It is the best indication of DKA risk.
You can go into DKA anytime your body is starving for more insulin and fuel, and this happens easily in D kids who aren't eating well. In our experience ketones are more dangerous when blood sugar is low, and Emma won't eat. This has been the cause of many hospitalizations for us!
Here is some good basic info from Abbott.
http://www.abbottdiabetescare.com/adc_dotcom/url/content/en_US/20.10.30:30/general_content/General_Content_0000032.htm
Until recently the only way to test for ketones was to use a urine test strip. This has some disadvantages:
Urine testing can only tell you ketones are present at a basic level - not how high your levels are. This method is therefore less specific.
There are three types of ketones - called acetone, acetoacetate and ß-hydroxybutyrate. The most common ketone when you are developing ketoacidosis is ß-hydroxybutyrate. Unfortunately urine tests don't detect ß-hydroxybutyrate.
Ketones accumulate in your urine over several hours, so measuring them in urine cannot tell you what your levels are right now.
When you have - or are developing - ketoacidosis you can become very dehydrated so a urine sample can be difficult to obtain.It is recommended you test your blood ß-Ketone because Ketones are detectable in the blood far earlier than in urine, so blood ß-Ketone testing can give early warning of impending DKA.
Who benefits most from blood ketone testing?
Pediatric patients with diabetes
To help parents detect and react swiftly to developing ketoacidosis
To help distinguish the symptoms of ketoacidosis from other childhood illnesses
Insulin pump users
In case of pump failure or catheter obstruction
Insulin users during illness or stress
To manage the risk of ketoacidosis and take action
When is it recommended to test?
During acute illness
During acute illness, infection or fever
Test ketone every 2-4 hours until better
Whenever symptoms of DKA are present
Nausea
Vomiting or diarrhea
Abdominal Pain
Fruity breath odor
Rapid breathing
Thirst and frequent urination
Fatigue or lethargy
When blood glucose remains elevatedWhat are Ketones?
In diabetes, there is not enough insulin to help your muscles absorb glucose from the blood. And when your muscles are starved for energy they start to "burn" fat. This produces breakdown products called ketones. These are toxic acids. The accumulation of these acids in the body may lead to the condition called ketosis and as it gets more serious, ketoacidosis or DKA.
Diabetic Ketoacidosis (DKA)
Occurs when excessive levels of ketone accumulate and the body becomes acidotic.
It is a potentially life-threatening condition.
β-Hydroxybutyrate is the predominant ketone associated with DKA.β-Hydroxybutyrate: A key to DKA Detection, Better Clinical Decisions
Sick-day management (http://www.abbottdiabetescare.com/adc_dotcom/url/content/en_US/20.10.30:30/general_content/General_Content_0000034.htm) requires increased monitoring of blood glucose and assessment for ketosis. Testing for β-Hydroxybutyrate is a key to early diabetic ketoacidosis (DKA) detection. Blood ketone testing methods are now available and preferred over urine ketone testing for diagnosing and monitoring ketoacidosis.
Clinically Accurate β-Hydroxybutyrate Measurements
β-Hydroxybutyrate ReadingInterpretation1.6 to 3.0 mmol/L
http://www.abbottdiabetescare.com/static/content/image/red_circle.gifReadings above 1.5 indicate you may be at risk of developing diabetic ketoacidosis or DKA. Contact your healthcare provider immediately for advice0.6 to 1.5 mmol/L
http://www.abbottdiabetescare.com/static/content/image/yellow_circle.gifReadings between 0.6 and 1.5 may indicate the development of a problem that may require medical assistance. Follow your healthcare provider's instructions.
Below 0.6 mmol/L
http://www.abbottdiabetescare.com/static/content/image/green_circle.gifReadings below 0.6 are in the normal range.
Amy: Thanks for the clarification. I guess things were getting a bit mixed up in my head. I must be getting a few things confused.
The reason I have been thinking on this is because we recently went through a long illness with Nathan. He had a high fever and on day three he threw up several times in the morning. Nathan develops ketones very easily. Leading up to the day of throwing up we had fought ketones and they, of course, got worse with the vomiting.
He was still running a fever and had a cough after 11 days. I had called the endo when necessary for the ketones and advice on insulin. I had also called the ped. When he woke up on day 11 with a fever and still bouncing up in the high 1's in ketones I decided I wanted to bring him in to be seen. Thankfully the nurse I talked to is the one who also has a son with diabetes. She also thought that long of fighting ketones was too long.
I brought him in and his dr. was sort of rude. He began by telling me that he understood that the reason I wanted him seen was because of the ketones, but if I could understand that starvation ketones develop when a child is not eating. All I had to do was feed him and they would be resolved. Excuse me? I told him that I never said he wasn't eating. That he was eating less, but he was consuming almost as many carbs as usual because flavored milk had suddenly become his favorite thing.
So he told me that I needed to give him insulin to correct the high sugars that he was getting from being sick. That ketones develop with high blood sugars. What high sugars? His numbers had been pretty on track. A little high here, a little low there. The ketones didn't care what his number was.
Finally he took a look at him and said he was fine and I should try a vaporizer. I had been doing that for a week. He finished by assuring me that I didn't have to worry about the ketones.
This guy always puts me on the defensive when it comes to diabetes care. When Nathan's a1c was 7.6 after beginning the pump he told me not to worry because the pump should help me get it lower--his target a1c for this age is 7.5-8.5. Everytime we go in he has something else to say.
I think maybe I got a bit off-track here:o
It has been bothering me that he was of such little help. We can't go to the endo for illness, but the ped. doesn't seem to understand enough to help sometimes. My mind must have conjured up the idea of the starvation ketones being exempt from the blood testing.
For anyone who has made it this far, thanks for your help. I despise ketones!
Nancy in VA
11-13-2007, 12:28 PM
You can have starvation ketones when you are eating.
When you are sick, your body needs MORE energy than normal to fight the illness. If they are eating less, their body takes all of that to fight the illness and THEN burns the fat because it still needs energy - thus the ketones.
So, you don't have to be "STARVING" to have starvation ketones - just not eating enough for your body at that moment. We had them when Emma was sick and just had to keep feeding her more often - every few hours, even overnight
Momof4gr8kids
11-13-2007, 12:59 PM
Lynn, This doesn't answer your original question, but it does go into the starvation v.s. DKA thing.
About a month ago, my six-year-old daughter, who has type 1 diabetes, had a pretty nasty stomach flu. She was able to hold down fluids, but not solids. She had normal to low readings throughout, but nothing too concerning or low. We were able to treat her with Powerade as needed for lows, plus every two hours. About 24 hours into this, she was able to hold down a few things, like applesauce and rice, but at that point her ketones (http://www.childrenwithdiabetes.com/dictionary/k.htm#Ketone%20Bodies) went from small/medium to large. When I called to get our Pediatric Endocrinologist's advice, he said that the ketones were starvation ketones and that they should start to clear soon now that she was eating solids and just keep an eye on her. We were to call him back or take her to the Emergency Room (ER) if she had signs of dehydration or started to vomit again. I have noticed on the CWD forums that most of the other children need an ER visit at this point, so it made me wonder if I should have taken her in anyway. Could you explain the difference between ketones from starvation and ketones from a high blood sugar? Also, why is no ER visit required for large ketones if they are from lack of food? And, do they require extra insulin still? Answer:
Large ketones (http://www.childrenwithdiabetes.com/dictionary/k.htm#Ketone%20Bodies) are clearly a sign of problems with your diabetes. Ketones can be caused by a lack of adequate food intake. These are typically called starvation ketones. These are more prevalent when a child has a stomach flu with vomiting and diarrhea and hasn't been able to eat appropriately. It is more common to have normal or low blood sugars with starvation ketones. These can very easily be confused with ketones from diabetic ketoacidosis (DKA). It is more common to have high blood sugars with these ketones.
Telling the difference between the two ketones can be difficult without a physician's expertise. I would always suggest that you review your child's condition with your diabetes physician or team if ketones are moderate or large. Starvation ketones are typically treated with fluids and restoration of adequate food intake. DKA ketones are treated typically with fluids and supplementary insulin under a physician's guidance.
Ivan's Mum
11-13-2007, 05:28 PM
for what it's worth
My non D son was ill and I thought for a bit of fun I'd stick a ketone stick in his nappy and it read hi ketones, which sent me into orbit. I phoned his doctors who asked if he'd been off colour and told me they were starvation ketones. Not to stress just feed him.
I believe non D's on things like Atkins (?) diet get them too. It's a sign of weight loss. I may be totally wrong on this but I remember a woman on telly dieting and taking a urine test to check for ketones and being delighted when she saw them!
I have a friend whos son often woke with ketones, 1 day starving with high ketones, and other days vomiting with high ketones. We wondered if these were different types of ketone situations.
EmmasMom
11-13-2007, 08:00 PM
I guess the most important distinction is...
If your child is still eating and drinking you should be able to clear them with additional insulin, moderate-large ketones in a child who is sick, BUT can still eat and drink are typically very treatable at home with careful management and close contact with a knowledgeable endo. :)
If your child is NOT able to eat and drink enough to continue insulin and clear the ketones you may be in trouble. If you have large ketones and can not give enough insulin to stop them, and your child is for example vomiting and can't hold down any carbs... you may need to go to the ER. :(
Ketones are ketones, they are acids that are toxic in high levels. If untreated your body chemistry changes, your PH level drops, your Co2 level drops and you get very, very sick. This is not easy to reverse once it happens, it is not uncommon, and it is the leading cause of hospital admission and death in children with diabetes.
Emma has had a low PH and CO2 with "starvation" ketones and low BG numbers on several occasions. The smell of acetone on her breath, (yes, it's just like finger nail polish remover) was a pretty clear indication to me that she was heading into DKA, but the labs at the ER definitely confirmed it.
My neighbor is a pedi ICU nurse and she sees kids all the time that have gone into severe DKA during a stomach bug with normal-low numbers. Parents are often only told to test for, or worry about ketones when numbers are high... this is simply not true.
If you're diabetic and have large ketones it is dangerous... no matter why you have them. I really feel like some doctors under-emphasize this point, so I like to over-emphasize it!;)
tandjjt
11-13-2007, 08:34 PM
Not sure if this is common but when Tyler is sick we use the ped for support in diagnosis of illness, prescription needs and all the things you use them for with a non-d child - HOWEVER - anything related to their D regardless if it is due to illness or not we call the endo for advise.
Example - Tyler was vomiting, low BG, large ketones -- called endo who told us to get w/the ped for an anti-nausea med to stop the vomiting and then talked us through what to do to get BG up so he could get insulin for the ketones. Called ped and explained situation - they called in zophran and told me to call back if we needed anything else - called endo to update and get further directions once the zophran kicked in - lucky enough, with all of our efforts, we avoided a trip to the ER.
It should be a team effort between the ped and the endo and parents.
Our endo is very specific about the role of the ped because they are not specialists and therefore do not always understand and advise the same as an endo would.
Heather(CA)
11-13-2007, 11:21 PM
An important thing to remember is that all ketones are from "starvation" in your body and high levels should always be taken very seriously. There are not different ketones for different circumstances, (fever, dieting, vomiting), they all cause the same ketones, but Beta-Hydroxybutyrate is the most important of three ketones in the blood. It is the best indication of DKA risk.
You can go into DKA anytime your body is starving for more insulin and fuel, and this happens easily in D kids who aren't eating well. In our experience ketones are more dangerous when blood sugar is low, and Emma won't eat. This has been the cause of many hospitalizations for us!
Here is some good basic info from Abbott.
http://www.abbottdiabetescare.com/adc_dotcom/url/content/en_US/20.10.30:30/general_content/General_Content_0000032.htm
Until recently the only way to test for ketones was to use a urine test strip. This has some disadvantages:
Urine testing can only tell you ketones are present at a basic level - not how high your levels are. This method is therefore less specific.
There are three types of ketones - called acetone, acetoacetate and ß-hydroxybutyrate. The most common ketone when you are developing ketoacidosis is ß-hydroxybutyrate. Unfortunately urine tests don't detect ß-hydroxybutyrate.
Ketones accumulate in your urine over several hours, so measuring them in urine cannot tell you what your levels are right now.
When you have - or are developing - ketoacidosis you can become very dehydrated so a urine sample can be difficult to obtain.It is recommended you test your blood ß-Ketone because Ketones are detectable in the blood far earlier than in urine, so blood ß-Ketone testing can give early warning of impending DKA.
Who benefits most from blood ketone testing?
Pediatric patients with diabetes
To help parents detect and react swiftly to developing ketoacidosis
To help distinguish the symptoms of ketoacidosis from other childhood illnesses
Insulin pump users
In case of pump failure or catheter obstruction
Insulin users during illness or stress
To manage the risk of ketoacidosis and take action
When is it recommended to test?
During acute illness
During acute illness, infection or fever
Test ketone every 2-4 hours until better
Whenever symptoms of DKA are present
Nausea
Vomiting or diarrhea
Abdominal Pain
Fruity breath odor
Rapid breathing
Thirst and frequent urination
Fatigue or lethargy
When blood glucose remains elevatedWhat are Ketones?
In diabetes, there is not enough insulin to help your muscles absorb glucose from the blood. And when your muscles are starved for energy they start to "burn" fat. This produces breakdown products called ketones. These are toxic acids. The accumulation of these acids in the body may lead to the condition called ketosis and as it gets more serious, ketoacidosis or DKA.
Diabetic Ketoacidosis (DKA)
Occurs when excessive levels of ketone accumulate and the body becomes acidotic.
It is a potentially life-threatening condition.
β-Hydroxybutyrate is the predominant ketone associated with DKA.β-Hydroxybutyrate: A key to DKA Detection, Better Clinical Decisions
Sick-day management (http://www.abbottdiabetescare.com/adc_dotcom/url/content/en_US/20.10.30:30/general_content/General_Content_0000034.htm) requires increased monitoring of blood glucose and assessment for ketosis. Testing for β-Hydroxybutyrate is a key to early diabetic ketoacidosis (DKA) detection. Blood ketone testing methods are now available and preferred over urine ketone testing for diagnosing and monitoring ketoacidosis.
Clinically Accurate β-Hydroxybutyrate Measurements
β-Hydroxybutyrate ReadingInterpretation1.6 to 3.0 mmol/L
http://www.abbottdiabetescare.com/static/content/image/red_circle.gifReadings above 1.5 indicate you may be at risk of developing diabetic ketoacidosis or DKA. Contact your healthcare provider immediately for advice0.6 to 1.5 mmol/L
http://www.abbottdiabetescare.com/static/content/image/yellow_circle.gifReadings between 0.6 and 1.5 may indicate the development of a problem that may require medical assistance. Follow your healthcare provider's instructions.
Below 0.6 mmol/L
http://www.abbottdiabetescare.com/static/content/image/green_circle.gifReadings below 0.6 are in the normal range.
WOW, thanks for all the great info...I just copied, pasted and emailed it to myself LOL
Mama Belle
11-14-2007, 01:01 AM
If you're diabetic and have large ketones it is dangerous... no matter why you have them. I really feel like some doctors under-emphasize this point, so I like to over-emphasize it!;)
Exactly. The one time we ended up in the hospital with Sam because of large ketones and low BGs (stomach flu) the resident tried to tell me that it was totally no big deal and that everyone gets ketones when they are sick. He was very condescending and rude. I asked him why it was that she was being kept at the hospital and not sent home if they were no big deal. He didn't have an answer for me. Idiot. The nurses ended up suggesting that I work around the resident and deal directly with the Barbara Davis Center on-call doc. Once that happened, our trip to the hospital went much better. God bless those lovely nurses!
Thank you all. The picture is clearing for me. These things always draw me to find answers when my brain is more than normally sleep-deprived. I can't process it all efficiently then.
Ketones make me crazy. Nathan gets them often, with the slightest illness. It made me mad when the ped. was pooh-poohing them.
It all just gets so tiring sometimes.
Lynn
Here's something I posted a while back on ketones, and which reflects my understanding of the issue:
"Ketones are produced ANY time the body burns fat to produce energy.
So when we see ketones in our DD/DS we have to try to be very clear about the cause, because different causes require different responses!
Possible common causes include:
1) Too little insulin in the bloodstream, with high BG.
In this case there is plenty of potential energy in the form of the high BG, but no way for it to get into the body's cells because the insulin is missing. To treat these ketones (seen when BG is high) we give extra insulin, which gets the energy the BG represents into the cells and stops the burning of fats.
2) "Starvation" ketones, with lower BG.
This occurs when not enough food has been eaten to fuel the body - can happen if child is sick and vomiting for a long time (not able to eat enough or keep food down) OR if dieting. BG will typically be lower. To treat these ketones, we give food AND insulin (to cover the carbs in the food). This gets energy into the cells, stops the burning of fats.
3) Sports ketones.
Prolonged aerobic exercise will see the body burning fat to fuel the muscles. BG will typically be low. To treat these ketones (which are a normal consequence of prolonged exercise), we give lots of food and REDUCED insulin to cover the carbs (because we know the body will be pulling down BG in the hours after exercise to refuel the muscles)..
Note that in both 1 and 2 the child can be vomiting. But in the case of 1, it is the high BG and ketones causing the vomiting. In the case of 2, the vomiting is depriving the body of food and causing the ketones.."
Hope this is helpful.
I think I missed this information when we went to classes after diagnosis.
During illness, is it possible to have starvation ketones AND high blood sugar? It seems that the ped. office assumes that starvation ketones are no big deal---and everytime he is sick and I call them they assume his ketones are starvation ketones. It is frustrating.
Also, I understand all ketones are bad. We do battle on a regular basis with them. I have noticed that at times they go away sooo easy and other times it is incredibly difficult to get that number down. He recently went from a 3.2 ketones to a 1.3 in an hour. Then there are times that I see the 1.3 to begin with and it takes many hours to get him down to a normal level. Why? Anyone have advice on how to treat each? I can guess what is the cause at times--Sick, needs adjustment of insulin, etc. Sometimes I need to give so much additional insulin to get them to budge and other times I try a little snack and the water bottle. Today Nathan has had a pretty good day with numbers. Then this afternoon he had a 410 out of the blue. I checked for ketones--.8. Crap. It took two water bottles and two extra boluses, given two hours apart, to get his number down at all (both blood sugar and ketones). Another two hours until they were down to .3. He isn't sick, his site is fresh and working. I guess I am looking to understand, not just treat mindlessly.
I appreciate all of your patience as I try to wrap my brain around all of this. I have always just gone on the, "Ketones are bad. Get rid of them." theory and not thought any further into it.
Thanks again,
Lynn
I think I missed this information when we went to classes after diagnosis.
During illness, is it possible to have starvation ketones AND high blood sugar? It seems that the ped. office assumes that starvation ketones are no big deal---and everytime he is sick and I call them they assume his ketones are starvation ketones. It is frustrating.
It IS hard to wrap your mind around. Essentially ketones are released any time the body switches to its alternative energy supply system and starts burning body fat for energy.
So when you're seeing ketones you need to ask yourself "why is the body burning fat?". There are 3 typical possibilities:
Possibility 1) Is it because your child has had little or no food and is literally starving?
This question is easy to answer, because you'll know if your child isn't eating. If this is what's happening, then these are "starvation ketones" and the child needs food (or a drink with carbs) plus some insulin to bolus for it.
Possibility 2) Is it because there is no insulin in the system, so the glucose that's available can't get into the cells?
This question is not quite as straightforward. A clue to indicate that there is no insulin in the system is if BG is sky-high. Note that this is the problem pumpers run into, in the event of a problem with the pump/site/tubing etc.
The way to treat this situation (lack of insulin in the system) is to give insulin, both correction bolus and basal. It will both help with the ketones and with bringing down the BG. Note that for pumpers it is advisable to give the correction by injection, so you know it's getting into the system and can be confident the ketones are starting to be addressed.
Possibility 3) Is fat being burned during sports?
The bodies of kids involved in very active sports will routinely switch to burning fat, because there just isn't enough glucose in the system to supply the energy needs of the muscles. This is a natural process.
If ketones are being seen regularly after sports, then the child needs to be getting a high carb drink/snack during the activity to help keep their energy levels up.
*********
As to the specific case you're referring to, 410 out of the blue on a good day would tend to indicate a problem with the pump/site/tubing. Your son isn't starving (otherwise we wouldn't have 410 BG!), and I'm assuming wasn't doing heavy sports either or you'd have mentioned it. So what is left is the likelihood of no insulin in the system. It could be an intermittent pump problem is giving you grief..