Diabetes Management: Effects of Persistent Ketosis

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What about long term concerns? High blood sugars and ketones accelerate complications related to diabetes as it is much more difficult for the diabetes team to manage insulin and related therapy. As a result of lost glucose in the urine, you may not achieve your ideal height. If you are a woman and choose to have a family in the future, it will also be much harder to achieve the tight diabetes control that is necessary to have a healthy baby (and healthy mother). Ketones make everything more difficult to manage.

The key point to remember is that ketones develop when there is a mismatch between glucose and insulin; lack of insulin results in ketone production, which causes increased difficulty in stabilizing blood sugars and managing diabetes. It is important to break this cyclical pattern to achieve the best possible diabetes control.

Guidelines for Treatment of Ketones (as recommended by Children’s National Medical Center):

1. Have available equipment: urine ketostix (we recommend individually foil wrapped strips) or Precision extra meter for blood ketone testing (strips that test for B-hydroxybuterate)

2. Increase ingestion of sugar free fluids (water, diet soda, etc.) Suggest 8 oz. every hour

3. Additional insulin administration depends on the type of insulin regime:

a. Traditional NPH/Regular/rapid acting insulin (2 or 3 injections)/day: if blood sugar is >/= 250 mg/dl and if ketones are >/=moderate, suggest administering ~20% of total daily dose as regular or rapid acting insulin. May repeat in 3-4 hours if ketones remain moderate or large.

b. Basal/bolus therapy: if ketones are >/=moderate, use correction factor plus 20% extra as rapid acting insulin. Give via injection if on an insulin pump for safety purposes and change catheter site.

c. Be careful if blood sugar is </=200 mg/dl and ketones are >/=moderate. You still require extra insulin but will need to raise blood sugar with glucose in order to safely give the insulin (and avoid a low).

4. If vomiting occurs and you are unable to keep fluids down, IV fluid administration is advisable. This means a trip to the emergency department.

5. Observe for signs of dehydration (decreased urination, decreased tears, dry mucous membranes). This also means a trip to the emergency department for IV fluids.

6. Don’t wait too long or Diabetic ketoacidosis may develop.

Please call your diabetes team for specific recommendations that may be unique to your institution.

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