T1 Topics Recap: Ketones and Sick Day Management

Rajiv Kumar (2)The cold and flu season has arrived, bringing a horde of unwelcome household guests — fever, chills, stuffy nose, sore throat, or worse. For people with type 1 diabetes, sick days bring extra challenges. Illness tends to elevate glucose levels, bringing the potential threat of diabetic ketoacidosis. At last week’s Peninsula Type 1 Topics talk, Dr. Rajiv Kumar, a pediatric endocrinologist at Stanford Medicine, spoke about ketones and sick day management for people with diabetes.  Here’s a summary of the talk:

What are ketones?

Ketones are substances that are made when the body breaks down fat for energy. If the body cannot use blood sugar (glucose)to fuel its cells, the body goes to an alternative fuel source: fat and muscles. When the body burns fat instead of glucose, a substance called ketones begin to form in the blood, and eventually spill over into the urine. When ketone levels soar to excessively high levels, Diabetic Ketoacidosis (DKA or ketoacidosis for short) occurs.

What causes ketoacidosis?

For a person with type 1 diabetes, insufficient insulin leads to ketoacidosis. This can occur in several ways:

  • Forgetting to give one or more insulin shots
  • Giving “spoiled” insulin
  • Insulin pump failure (such as kinked, blocked, or disconnected tubing)
  • Stress due to illness or trauma can cause blood sugar to rise, and render insulin less effective
  • In an accident, emergency personnel may not know the person has type 1 diabetes, so insulin will not be administered (that’s why wearing a medical id bracelets are so important!)

What are the symptoms of ketoacidosis?

  • Nausea and vomiting – the buildup of acidic ketones will make the patient sick to the stomach
  • Frequent urination – Since there is insufficient insulin to process glucose, glucose builds up in the blood, and the kidneys must continuously dump the glucose out into the urine.
  • Dehydration – Vomiting and increased urination can result in severe dehydration (physical symptoms include dry mouth).
  • Acidic, “fruity” breath – The patient’s breath may smell like fruit or nail polish remover (the acetone compounds are similar)

Rajiv Kumar (8)How can ketoacidosis be prevented?

  • Stay hydrated
  • Check ketones whenever blood sugar is unexpectedly high (ketones can be checked with blood ketone meters or urine tests)
  • Check ketones at regular intervals during periods of illness, even if blood sugar is at target range or low
  • Avoid exercise when ketone levels are elevated, because exercise requires the body to produce fuel, which produces even more ketones
  • Have a sick day plan
  • Call your diabetes medical professional if urine ketones are moderate or large, or if blood ketones are > 1.0 mmol/L

What should I do during sick days?

Insulin and hydration are the key. Follow the steps outlined below, and don’t wait for vomiting to start!Rajiv Kumar (11)

  • Have the patient sit or lie down and avoid movement.
  • Keep the patient hydrated by drinking from a straw in small, slow sips to prevent vomiting.
  • Increase the patient’s blood sugar slowly by grazing on gentle carbohydrates (i.e. saltines and other foods from the BRAT diet).
  • Give a bolus of insulin to bring ketone levels down.
  • Do this every 3 hours.

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