Is a patient with positive ketones at risk of a serious condition and what is the appropriate management protocol?

From the Guidelines

Positive ketones in a patient can indicate diabetic ketoacidosis (DKA), a serious and potentially life-threatening condition that requires immediate medical attention. Management of DKA should prioritize fluid resuscitation, insulin therapy, and electrolyte replacement to minimize morbidity, mortality, and improve quality of life. The most recent and highest quality study 1 recommends the following management protocol:

• Fluid resuscitation using intravenous normal saline at 15-20 mL/kg/hr initially
• Continuous insulin therapy with regular insulin at 0.1 units/kg/hr after an optional bolus of 0.1 units/kg
• Electrolyte replacement, particularly potassium, to maintain serum potassium between 4-5 mEq/L
• Hourly monitoring of blood glucose, and when levels reach 200-250 mg/dL, add dextrose to IV fluids while continuing insulin to clear ketones
• Frequent monitoring of vital signs, mental status, electrolytes, and blood gases The underlying cause of ketosis must be identified and addressed, which may include infection, medication non-compliance, or new-onset diabetes, as noted in 1, 1, and 1. Ketones develop when the body cannot use glucose for energy and breaks down fat instead, producing ketone bodies that acidify the blood, leading to the symptoms of DKA including vomiting, abdominal pain, fruity breath, and altered mental status. It is essential to individualize treatment based on a careful clinical and laboratory assessment, as emphasized in 1 and 1. Successful transition from intravenous to subcutaneous insulin requires administration of basal insulin 2–4 h prior to the intravenous insulin being stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia, as recommended in 1 and 1. Clear communication with outpatient providers either directly or via hospital discharge summaries facilitates safe transition of care, as noted in 1. By following this management protocol and prioritizing the patient's morbidity, mortality, and quality of life, healthcare providers can effectively treat DKA and prevent complications. Key considerations in DKA management include:
• Restoration of circulatory volume and tissue perfusion
• Resolution of ketoacidosis
• Correction of electrolyte imbalance and acidosis
• Treatment of any correctable underlying cause of DKA, such as sepsis, myocardial infarction, or stroke, as emphasized in 1. By addressing these key considerations and following the recommended management protocol, healthcare providers can provide high-quality care for patients with DKA and improve outcomes.

From the FDA Drug Label

When you are sick, test your blood glucose frequently If instructed by your doctor, test your ketones and report the results to your doctor. Hyperglycemia (too much glucose in the blood) may develop if your body has too little insulin Hyperglycemia can be brought about by any of the following: ... In patients with type 1 or insulin-dependent diabetes, prolonged hyperglycemia can result in DKA (a life-threatening emergency) The first symptoms of DKA usually come on gradually, over a period of hours or days, and include a drowsy feeling, flushed face, thirst, loss of appetite, and fruity odor on the breath. With DKA, blood and urine tests show large amounts of glucose and ketones.

Positive ketones can be a sign of a serious condition, such as diabetic ketoacidosis (DKA), which is a life-threatening emergency.

• Key steps to follow:
  • Test blood glucose frequently
  • Test ketones if instructed by the doctor
  • Report the results to the doctor
  • Seek medical assistance immediately if symptoms of DKA occur, such as a drowsy feeling, flushed face, thirst, loss of appetite, and fruity odor on the breath. 2

From the Research

Diagnosis and Risks

• A patient with positive ketones is at risk of a serious condition, specifically diabetic ketoacidosis (DKA) 3, 4, 5, 6, 7.
• DKA is a severe metabolic derangement characterized by dehydration, loss of electrolytes, hyperglycemia, hyperketonemia, acidosis, and progressive loss of consciousness 3.
• The biochemical criteria for diagnosis of DKA include blood glucose > 200 mg/dl, venous pH <7.3 or bicarbonate <15 mEq/L, ketonemia >3 mmol/L, and presence of ketonuria 3.

Management Protocol

• The appropriate management protocol for DKA includes:
  • Restoration of circulating volume and electrolyte replacement 3, 5, 7.
  • Correction of insulin deficiency aiming at the resolution of metabolic acidosis and ketosis 3, 4, 6.
  • Reduction of risk of cerebral edema 3, 6.
  • Avoidance of other complications of therapy (hypoglycemia, hypokalemia, hyperkalemia, hyperchloremic acidosis) 3, 7.
  • Identification and treatment of precipitating events 3, 7.
• Treatment guidelines may vary depending on the specific circumstances, such as the use of SGLT-2 inhibitors, which can cause euglycemic DKA 4.
• In general, treatment includes administering intravenous fluids and insulin, and monitoring glucose and electrolyte levels 6, 7.