Hyperketonemia needing sick day rules or DKA

Question 1: What should be done with this patient?

As patient is unwell and has type 1 diabetes, her ketone meter reading capillary tests also show:
1.1 mmol/l ketone (0-0.5) and 16.7 mmol/l glucose. This means that she is sick, and her glucose
levels is higher (300 mg/dl) than average (240 mg/dL). She needs to monitor her urine for
ketones using a ketone kit over the counter, and then call her doctor since her ketones are high.
(CDC. 2020, June 2). Since her ketones range is 1.1 mmol/l and her amount is between 0.6 and
1.5 mmol/L, she has ketones in her blood, this may become an issue if not handled. She should
contact her healthcare provider and adhere to his or her recommendations. (Gary Gilles. 2019,
November 27). High ketones may be a symptom of diabetic ketoacidosis, and is a serious
emergency that involves urgent care. DKA (diabetic ketoacidosis) is a potentially lethal diabetes
complication that happens when fat is broken down for energy and ketones are released too
rapidly and accumulate in the body. Some doctors may advise her to become more active. Daily
exercise will help her maintain a stable blood sugar level. However, she should not exercise
because ketones are found in her urine. This could increase her blood sugar even more.

Question 2: When next should the patient recheck her glucose and ketones?

Since she is ill, if she may not follow the basic rules, her blood glucose and ketones levels can
become dangerously high. She should not stop taking her insulin. She should recheck her glucose
and ketones according to the following measures:

 Every two hours, she should monitor blood glucose levels (Checking too frequently does
not have much advantage)
 Monitor ketones every two hours for blood or urine.
 Insulin-She might need to raise her insulin rapidly. She ought to have extra fast acting
insulin. Since her blood glucose is more than 10mmol/l, whether or not she eats.
 She needs to drink at least 100 ml of water or beverages free of sugar per hour.
 Take paracetamol or ibuprofen on a daily basis to lower her temperature and help her feel
better.

(South Tees Hospitals NHS Foundation Trust. 2018)

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Question 3:

 Hb 13.6g/dl (12-16): She has a normal hemoglobin levels

 White cell count 11.6 (3-8): A high number of white blood cells is not a disorder in and
of itself, it may signify the existence of an underlying issue such as illness, inflammation,
stress, wound, asthma, or certain diseases.
 CRP 25 mg/dl (<5): Patients of Legionella infection have an approximately 7-fold
higher risk of developing a CRP dose > 25 mg/dL than patients with pneumonia from
other sources.
 Sodium 148 mmol/l (134-144): It suggest that she has an abnormal amount of sodium in
her blood (hypernatremia).
 Potassium 3.5 mmol/l (3.5-5): She has a normal or safe level of potassium.
 Urea 5.6 mmol/l (3-8): She has a normal urea blood level.
 Creatinine 100 micromol/l (50-100): She has a normal creatinine blood test
 Glucose 11.2 mmol/l: As she has a type 1 diabetes her blood sugar level is usually higher
than normal level.
 Arterial Blood gas: pH 7.35 (7.35-7.45): Her blood pH range lies in normal range.
Below than this represents that blood is acidic.
 Bicarbonate 20 mol/l (22-28): A lower level of bicarbonate can cause a metabolic
acidosis in the blood or an enormous amount of acid in the body. Metabolic acidosis can
be caused by a variety of disorders, including diarrhea, kidney dysfunction, and liver
failure.

Question 4: Besides the urine tract infection, what is the diagnosis?

The doctor will need to test patient urine for bacteria in order to confirm a diagnosis of UTI.

Patients should send a "clean catch" sample to the urine sample their doctor offers. This indicates
that the urine sample is obtained rather than at the beginning in the middle of the urinary stream.
This helps prevent the collection of your skin of bacteria or yeast that may pollute the sample.
Patients will be told by their doctor how to get a clean catch. The doctor will look at a high
amount of white blood cells in the urine before inspecting the sample. An illness may be
indicated. The doctor will also screen for bacteria or fungi in a urinary culture. The culture will

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help to determine the cause. It will even help a health care provider find the best medication for
patient. Special tests could be required if a virus is detected. In patients that have organ
transplantation or other illnesses that damage the immune system, viruses are severe causes of
UTIs. (Lights, V. 2020, July 29)

Question 5: What's the value of ketone meters?

Normal levels of blood ketone vary significantly from person-to-person. In general, this table
assists with the labelling of ketone test values as follows: (Ketone testing. 2016)

Blood Ketone Value What should we do

Less than 0.6 mmol/L Values of less than 0.6 mmol/L are normal.
Seek the recommendation of a healthcare
provider before modifying the medication for
diabetes.
Between 0.6 mmol/L and 1.5 mmol/L Values in this range can suggest the
production of an issue with blood glucose
levels greater than 13.9 mmol/L.
Follow the guidance of the healthcare
provider.
Higher than 1.5 mmol/L Values over 1.5 mmol/L with a level of blood
glucose above 16.7 mmol/l indicate that DKA
(diabetic ketoacidosis) may develop.
Question 6: Titrating the dose of insulin and sick day rules?

It is empirically possible to normalize FPG with basal insulin in 10 units a day or 0.15 U/kg/day
at a low dose. Patients can titrate the 2 unit at a time, each of two or three days, depending on the
SMBG, before the function of FPG can be satisfied. For all patients without current treatment
the more intense starting dosage is 0.3 U / kg and over 8.5 percent is HbA1c. (Triplitt, C., et al.
2007, October 18).

Question 7: How do you diagnose DKA?

The doctor will do a physical examination and prescribe blood tests if the patient's doctor
suspects DKA. Blood tests for DKA are used to measure:

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  Blood sugar levels: If patient’s body does not have enough sugar to allow their cells to
enter, their blood sugar will increase their level (hyperglycemia). Patient’s blood sugar
level continues to increase as their body breaks down fat and protein for energy.
 Ketones level: Acids known as ketones penetrate the bloodstream.
 Blood acidity: Patient’s blood can turn acidic if they have excess ketones in their blood
(acidosis). This will affect the body's normal functioning.

(Mayo Clinic. 2019, December 11)

Question 8: Most appropriate treatment of DKA?

Patients with DKA diagnosis may be treated or admitted into the hospital in an emergency room.
Typically the treatment includes:

 Replacement of fluids: Until they're rehydrated, they'll be given fluids by mouth or by a

vein.
 Electrolyte replacement: Insulin absence will reduce the amount of many electrolytes in
blood patients. They absorb electrolytes through the vein to help maintain proper function
of the heart, muscles and nerve cells.
 Therapy with insulin: The mechanism of DKA is reversed by insulin. Patient undergo
insulin injection, normally via the vein, in addition to fluids and electrolytes. They will be
able to end intravenous insulin therapy and restart their daily subcutaneous insulin
therapy until their blood sugar level drops to around 11.1 mmol/L (200 mg/dL) and thier
blood is no longer an acidic one.

(Mayo Clinic. 2019, December 11)

References:

 CDC. (2020, June 2). Manage blood sugar. Centers for Disease Control and Prevention.
https://www.cdc.gov/diabetes/managing/manage-blood-sugar.html
 Gary Gilles. (2019, November 27). How to recognize a reading that warrants a call to
your doctor. Verywell Health. https://www.verywellhealth.com/how-to-read-blood-
ketone-test-results-3289640

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 Ketone testing. (2016). FreeStyle Glucose Meters | Official FreeStyle Diabetes UK
Website. https://freestylediabetes.co.uk/managing-and-monitoring/ketone-testing
 Lights, V. (2020, July 29). Urinary tract infection: Symptoms, diagnosis, and treatment.
Healthline. https://www.healthline.com/health/urinary-tract-infection-adults#diagnosis
 Mayo Clinic. (2019, December 11). Diabetic ketoacidosis - Diagnosis and treatment -
Mayo Clinic. Mayo Clinic - Mayo Clinic. https://www.mayoclinic.org/diseases-
conditions/diabetic-ketoacidosis/diagnosis-treatment/drc-20371555
 South Tees Hospitals NHS Foundation Trust. (2018). Sick day rulesassociated with
insulin dependent diabetes. www.southtees.nhs.uk.
https://www.southtees.nhs.uk/content/uploads/Sick-Day-Rules.pdf
 Triplitt, C., Professor, C. A., & Department of Medicine, Division of Diabetes, Clinical
Assistant Professor of Pharmacy, Texas Diabetes Institute University of Texas Health
Science Center at San Antonio, San Antonio, Texas. (2007, October 18). How to initiate,
titrate, and intensify insulin treatment in type 2 diabetes. U.S. Pharmacist – The Leading
Journal in Pharmacy. https://www.uspharmacist.com/article/how-to-initiate-titrate-and-
intensify-insulin-treatment-in-type-2-diabetes