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April 25, 2008

Hyperglycemia and DKA

Question from Brakpan, Gauteng, South Africa:

My kids were on a pump for a year. The girl started having ketones once a month. After some time, she had ketones up to two times a week. I called the doctor to ask about this, but he never called me back. Her blood sugars range from 2.9 mmol/L [53 mg/dl] to 20 mmol/L [360 mg/dl]. They say it is normal for a child that age. I took both of them off the pump without any assistance from a doctor. Can you explain the ketones?

Answer:

Ketones measured in the blood and/or the urine merely indicate that the body is metabolizing fat. This can happen with starvation or undernutrition or can happen when there is a lack of insulin (omitted insulin, no insulin provided as at diagnosis of diabetes, etc.). In someone with diabetes, using shots or pumps does not matter, the presence of ketones is not normal, but indicates a mis-match of insulin, food/energy. In pump patients, interruption of insulin either by purposeful omission of insulin, catheter blockage, air in the catheter, or pump malfunction itself all are additional possible explanations added to illness interfering with insulin effects. Frequent ketones suggest the need for some “detective” work closely with the diabetes health care team and family to try to elucidate possible causes and make some corrections. It is not likely that illness would explain this but significant psychological stress of any kind can block insulin’s effect just as catheter/site problems or lack of insulin are likely culprits. The one other explanation for positive ketones is in someone who is trying to lose weight because of being overweight/obese. Then, ketones would be a good sign that the body fat is being metabolized appropriately.

SB