Evaluation of a point-of-care glucose and

β-hydroxybutyrate meter operated in various

environmental conditions in prepartum
and postpartum sheep

Katlin J. Hornig, BS; Stacey R. Byers, DVM, MS; Robert J. Callan, DVM, PhD; Timothy Holt, DVM;
Megan Field, PhD; Hyungchul Han, PhD

Objective—To compare β-hydroxybutyrate (BHB) and glucose concentrations measured

with a dual-purpose point-of-care (POC) meter designed for use in humans and a laboratory
biochemical analyzer (LBA) to determine whether the POC meter would be reliable for on-
farm measurement of blood glucose and BHB concentrations in sheep in various environ-
mental conditions and nutritional states.
Animals—36 pregnant mixed-breed ewes involved in a maternal feed restriction study.
Procedures—Blood samples were collected from each sheep at multiple points through-
out gestation and lactation to allow for tracking of gradually increasing metabolic hardship.
Whole blood glucose and BHB concentrations were measured with the POC meter and
compared with serum results obtained with an LBA.
Results—464 samples were collected. Whole blood BHB concentrations measured with
the POC meter compared well with LBA results, and error grid analysis showed the POC
values were acceptable. Whole blood glucose concentrations measured with the POC me-
ter had more variation, compared with LBA values, over the glucose ranges evaluated. Re-
sults of error grid analysis of POC-measured glucose concentrations were not acceptable,
indicating errors likely to result in needless treatment with glucose or other supplemental
energy sources in normoglycemic sheep.
Conclusions and Clinical Relevance—The POC meter was user-friendly and performed
well across a wide range of conditions. The meter was adequate for detection of pregnancy
toxemia in sheep via whole blood BHB concentration. Results should be interpreted with
caution when the POC meter is used to measure blood glucose concentrations. (Am J Vet
Res 2013;74:1059–1065)

P regnancy toxemia, also known as pregnancy ketosis,

is a metabolic disorder that can develop as a result of
relative undernourishment or excessive body condition
in late-gestation ewes, typically those bearing twin or
multiple fetuses.1 A suspicion of clinical pregnancy tox-
emia is supported by a ewe’s history and signalment as
well as a progression of signs such as anorexia, lethargy,
weakness, and neurologic abnormalities.2 When unde-
tected or left untreated, the condition usually results in
death of the ewe and its fetuses.
Treatment of pregnancy toxemia can have disap-
pointing results and be expensive and time-consuming,
particularly when multiple sheep are affected or when
Received December 1, 2012.
Accepted April 2, 2013.
From the Department of Clinical Sciences, College of Veterinary Med-
icine and Biomedical Sciences (Hornig, Byers, Callan, Holt), and
the Department of Animal Sciences, College of Agriculture Sciences
(Field, Han), Colorado State University, Fort Collins, CO 80523.
Supported with start-up funds provided to Dr. Byers.
Presented in abstract form at the American College of Veterinary In-
ternal Medicine Forum, New Orleans, June 2012.
Address correspondence to Dr. Byers (stacey.byers@colostate.edu).
BHB
ABBREVIATIONS
β-Hydroxybutyrate
CV Coefficient of variation
dGA Days of gestational age
LBA Laboratory biochemical analyzer
POC Point of care
detection is delayed, resulting in an increase in the se-
verity of clinical signs. Therefore, a rapid and accurate
diagnosis of ketosis could increase the possibility of a
successful treatment outcome while decreasing the like-
lihood of illness and death of affected ewes and lambs
and lessening economic costs associated with delayed
treatment and sheep loss.
Sheep producers and veterinarians typically use
urine ketone test strips to evaluate ketone status in late-
gestation ewes. The urine ketone strips can be used to
semiquantitatively measure the amount of acetoacetate
in urine but not of BHB, which is the primary circu-
lating ketone body.3 Accuracy of the urine ketone test
strips in dairy cows is reportedly variable, and results
can be affected by environmental conditions (eg, ambi-

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 ent humidity or temperature), user characteristics (eg,
nature of handling and interval from testing to reading),
some medications, and pigmenturia.4,5 Urine collection
can be difficult and is stressful for ewes because urina-
tion is most reliably induced by restraining the ewe and
holding off the nares to prevent breathing.6 The ewe
eventually becomes distressed and postures to urinate.
A POC meter designed to measure blood glucose
and BHB concentration in humans has been evalu-
ated for detection of ketosis in dairy cattle and dairy
sheep.7–9 The only other method for measuring blood
BHB concentrations in prepartum animals is with an
LBA. A POC glucometer is available for veterinary use;
however, it has not been evaluated or marketed for use
in sheep.
Although blood glucose concentrations vary in sheep
with pregnancy toxemia, they can be used to assist in
evaluating response to treatment. Therefore, a reliable
POC meter capable of measuring both BHB and glucose
concentrations would be beneficial and economical for
sheep producers and veterinarians. The objective of the
study reported here was to compare blood BHB and glu-
cose concentrations measured with a dual-purpose POC
meter with those of an LBA in various environmental con-
ditions and throughout gestation and lactation in healthy
and nutritionally stressed ewes at high risk for developing
pregnancy toxemia. The hypothesis was that the POC me-
ter would yield results of sufficient accuracy to support its
use for measurement of blood BHB and glucose concen-
trations in sheep on farms.
Materials and Methods
Animals—Thirty-six adult mixed-breed white-face
ewes were used for the study. Each ewe was identified
with a unique ear tag number. The sheep were concur-
rently involved in an unreported study of maternal nu-
tritional energy restriction and were assigned equally
into 3 study groups. Group 1 (control group) was fed
100% of their nutrient requirements, group 2 was fed
50% of their nutrient requirements from 28 through
78 dGA, and group 3 was fed 50% of their nutrient re-
quirements from 28 dGA through parturition. Nutri-
ent requirements were based on the National Research
Council’s recommendations for twin-bearing ewes in
early and late gestation. The ewes were housed in in-
dividual sand pens with individual automatic waterers
and feed pans to control their feed intake. All pens were
located within a 3-sided barn that was not temperature
regulated.
Ovulation in the ewes was synchronized, after
which they were exposed to a ram at 12-hour intervals
for a 2-day period. The second day of exposure to the
ram was used as the breeding date for the study. Trans-
abdominal ultrasonography was performed on ewes ob-
served to have been bred at 45 days after breeding (45
dGA), and ewes confirmed to be pregnant with twins
were selected for the maternal malnutrition study. The
study protocol was approved by the Colorado State Uni-
versity Institutional Animal Care and Use Committee.
Blood sample collection—Blood samples were col-
lected from each ewe throughout gestation at the fol-
lowing intervals: once at 3 time points from 20 through
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22 dGA, 75 through 80 dGA, and 88 through 90 dGA;
and weekly thereafter from 91 dGA through parturition
(at approx 147 to 152 dGA). Postpartum samples were
collected once per day until serum BHB concentrations
were < 1.0 mmol/L, then every 2 weeks for 6 weeks, and
again when lambs were weaned (approx 11 to 12 weeks
after parturition). For sample collection, each ewe was
restrained within its pen by 1 person while a second
person obtained the blood sample via jugular veni-
puncture with an 18-gauge, 2.8-cm needle and 12-mL
syringe.
BHB and glucose concentration measurement—
Immediately after collection, blood samples were ana-
lyzed with each of 2 dual-purpose POC metersa: one
calibrated for BHB measurement and the other cali-
brated for glucose measurement. Meter calibration was
performed in accordance with the manufacturer’s in-
structions by insertion of a calibrator key specific to the
BHB or glucose test strips into the meter. A lot code
was matched between the calibrator key and the test
strips. Calibration was performed prior to each blood
collection day and when lot numbers changed between
test strips. The POC meters were designed to measure
whole blood BHB concentrations between 0.0 and 8.0
mmol/L10 and glucose concentrations from 20 to 500
mg/dL.11 Samples were immediately retested with a new
test strip whenever the meter displayed an error code or
provided a result of high or low.
Before the study began, the precision of the POC
meter had been tested by use of whole blood samples
collected from a nonpregnant sheep and a ketotic cow.
A whole blood sample (3 mL) collected by jugular or
coccygeal venipuncture had been immediately tested
10 times with the 2 POC meters calibrated for study
BHB and glucose measurements, and the CV had been
calculated for each analyte.
The POC meters were evaluated in various con-
ditions, which included environmental temperatures
ranging from –10° to 25°C, dusty conditions, and wet
(rain and snow) conditions given the open barn design.
The 2 meters and test strips were stored in small, insu-
lated coolers with chemical hand warmersb when en-
vironmental temperatures were lower than the meters’
operating temperature range (10° to 50°C). Extra test
strips were stored in their original packaging between
10° and 25°C.
The remainder of each blood sample was trans-
ferred into evacuated serum tubesc and stored on ice
prior to transport to the Colorado State University
Clinical Pathology Laboratory. Within 3 hours after
sample collection, the serum tubes containing clotted
blood were centrifuged for 5 minutes at 1,000 X g, se-
rum was harvested, and serum samples were refriger-
ated overnight. The serum BHB and glucose concen-
trations were measured with an LBAd within 24 hours
after blood sample collection. The LBA was calibrated
in accordance with the manufacturer’s instructions.
The analyzer measured serum BHB concentration with
a spectrophotometric method and glucose concentra-
tions with a hexokinase method.
Statistical analysis—Data were analyzed with the
aid of a commercial software package.e The D’Agostino-
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 Pearson test indicated that the data from blood sample
testing were not normally distributed, so nonparamet-
ric analyses were used. The Wilcoxon test was used to
determine whether the POC meter results for blood
BHB and glucose concentrations were significantly dif-
ferent from the LBA results for serum BHB and glucose
concentrations. The Spearman rank correlation coeffi-
cient (ρ) was calculated to assess correlations between
POC meter and LBA results. The percentage difference
between the POC meter and LBA results was calculated
for each paired whole blood and serum BHB or glucose
value. Percentages of POC meter results for BHB and
glucose that were within 5%, 10%, and 20% above or
below the LBA values were then calculated.
Agreement between results of the POC meter and
the LBA was assessed via Bland-Altman methods for
multiple observations per test subject,12 and plots were
constructed so that the identities of sheep could be dis-
cerned by feeding group. Bland-Altman plots describe
the limits of agreement between 2 methods as the mean
difference between measurements ± 1.96 SD. Through
examination of the plotted data, one can detect system-
atic biases (mean difference) and proportional biases
(positive or negative slope in the data). The LBA was
considered the gold standard method in these analyses.
Error grid plots were developed to theoretically
evaluate the results of clinical decisions regarding
whether the POC meter BHB or glucose concentration
should be used rather than the LBA concentration. To
do this, the Clarke error grid analysis method and ac-
ceptance criteria were modified because the critical lim-
its pertinent to sheep are different from those used in
humans.13 On the BHB plot, zone A represented POC
meter BHB concentrations within 20% above or below
the LBA concentrations as well as when the POC BHB
concentration was < 0.8 mmol/L and the correspond-
ing LBA BHB concentration was also < 0.8 mmol/L.
Zone B contained POC meter concentrations that were
> 20% of LBA concentrations but would result in a be-
nign treatment decision. Zone C contained POC meter
BHB concentrations that would result in not treating
a sheep when the LBA BHB concentration was higher
than the acceptable range, and zone D contained POC
concentrations that would result in treating a sheep
when the LBA BHB concentration was within the ac-
ceptable range. These zones were established with the
Table 1—Median (interquartile range) blood concentrations of BHB and glucose as measured with a
POC meter and serum concentrations as measured with an LBA in 36 pregnant mixed-breed ewes
with different feeding regimens* (12 sheep/group).
presumption that treatment would be deemed neces-
sary in a clinical setting when the BHB concentration
was ≥ 0.8 mmol/L. No lower limit for intervention was
deemed necessary for this study.
For the glucose concentration error grid plot, zone
A represented the POC meter glucose concentrations
that were within 20% above or below the LBA concen-
trations as well as when the POC concentration was ≤
50 mg/dL when the LBA concentration was also ≤ 50
mg/dL. Zone B contained the POC meter glucose con-
centrations that were > 20% of LBA concentrations but
would result in a benign treatment decision or no treat-
ment decision. Zone C contained the POC glucose con-
centrations that would result in treating a sheep when
the LBA glucose concentration was within the accept-
able range, and zone D contained POC glucose concen-
trations that would result in not treating a sheep when
the LBA concentration was lower than the acceptable
range. The zones were established with the presump-
tion that treatment would be deemed necessary when
the glucose concentration was ≤ 50 mg/dL. No upper
limit for treatment intervention was deemed necessary
for glucose concentrations. The meter would be con-
sidered acceptable for on-farm use if at least 95% of the
BHB or glucose concentration were within zones A and
B. The BHB and glucose concentration intervention
guidelines were not implemented in this study. Values
of P ≤ 0.05 were considered significant. Device results
are summarized as mean ± SD.
Results
Blood samples—Four hundred sixty-four blood
samples were obtained from the 36 ewes over the study
period. Three blood samples were not used in BHB or
glucose concentration statistical analyses because of
gross hemolysis that occurred during collection. Addi-
tionally, 16 blood glucose concentrations were reported
as low (< 20 mg/dL) by the POC meter and remained
low despite retesting. The corresponding serum LBA
glucose concentrations ranged from 10 to 71 mg/dL.
These values were omitted from the statistical analy-
ses. Error codes were randomly displayed by the meter
but were not documented. The manufacturer’s instruc-
tions recommended verification that the meter had
been properly calibrated and retesting of samples with

BHB (mmol/L) Glucose (mg/dL)

No. of No. of
samples samples
Animals tested POC LBA tested POC LBA
All 461 0.30 (0.10–0.70) 0.42 (0.28–0.73) 446 42 (34–54) 54 (48–61)
Group 1* 161 0.30 (0.20–0.70) 0.44 (0.27–0.74) 158 43 (35–54) 55 (50–62)
Group 2* 200 0.30 (0.10–0.70) 0.38 (0.27–0.69) 193 41 (33–53) 52 (47–60)
Group 3* 100 0.30 (0.20–0.75) 0.47 (0.30–0.76) 95 40 (33–55) 53 (45–62)
*Sheep in group 1 were fed 100% of their nutrient requirements, those in group 2 were fed 50% of their
nutrient requirements from 28 through 78 dGA, and those in group 3 were fed 50% of their nutrient require-
ments from 28 dGA through parturition.
The LBA was considered the more accurate method. All median values differ significantly (P < 0.001)
between devices.

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 a new test strip. Following these recommendations led
to resolution of the error code display and obtainment
of valid measurements, which were used in the statis-
tical analyses.
Precision testing—Precision testing of the POC
meters revealed a smaller CV for BHB concentrations
than for glucose concentrations, and the CVs were
similar to those reported by the meter manufacturer.10
The high BHB concentration CV, obtained through use
of bovine blood samples, was 3.56% (mean ± SD, 3.92
Figure 1—Error grid analysis (A) and Bland-Altman plot (B) com-
paring blood BHB concentrations measured with a dual-purpose
POC meter with serum BHB concentrations measured with an
LBA in samples obtained from pregnant mixed-breed ewes with
different feeding regimens. Sheep in group 1 (triangles; n = 12)
were fed 100% of their nutrient requirements, those in group 2
(squares; 12) were fed 50% of their nutrient requirements from
28 through 78 dGA, and those in group 3 (circles; 12) were fed
50% of their nutrient requirements from 28 dGA through parturi-
tion. A—The error grid comprises 4 zones. Zone A represents
POC meter BHB concentrations within 20% of the LBA concen-
trations as well as when the POC BHB concentration was < 0.8
mmol/L and the corresponding LBA BHB concentration was also
< 0.8 mmol/L. Zone B contains POC meter values that were
> 20% of LBA values but would result in a benign treatment deci-
sion. Zone C contained POC meter BHB concentrations that would
result in not treating a sheep when the LBA BHB cocentration was
above the acceptable range, and zone D contained POC concen-
trations that would result in treating a sheep when the LBA BHB
concentration was within the acceptable range. B—Bland-Altman
difference plots were prepared, accounting for multiple observa-
tions per test subject. The dashed lines indicate the 95% limits of
agreement (± 1.96 SD of the mean difference), and the solid line
indicates the mean difference between methods.
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± 0.14 mmol/L), and the low BHB concentration CV,
obtained through use of ovine blood samples, was not
relevant because the mean was close to 0 mmol/L (0.12
± 0.042 mmol/L). The CV reported by the meter manu-
facturer was 3.8% for the mid BHB concentration range
(2.36 ± 0.09 mmol/L) and 3.1% for the high range (6.32
± 0.2 mmol/L), and a CV was not reported for the low
BHB concentration range (0.34 ± 0.03 mmol/L). The
CV for the glucose concentration (sheep blood sample)
was 5.8% (52.5 ± 3.0 mg/dL), compared with the man-
ufacturer’s reported CV of 6% for the low glucose con-
centration range (43.9 ± 2.3 mg/dL).11
POC meter and LBA comparisons—The POC me-
ter results for blood BHB and glucose concentrations
differed significantly (P < 0.001) from the LBA results
for serum concentrations overall and by feeding group
(Table 1). The correlation between the POC meter and
LBA values was 0.934 (P < 0.001) for BHB concentra-
tion and 0.620 (P < 0.001) for glucose concentration.
The percentage difference in values obtained with
the POC meter and LBA indicated the POC meter re-
sults for blood BHB and glucose concentrations were
quite different from the LBA results. For BHB values,
13%, 21%, and 37% of POC meter concentrations were
within 5%, 10% and 20% above or below the LBA values,
respectively. Because meter performance criteria have
not been established for blood BHB concentrations,
samples were analyzed further when the LBA-measured
BHB concentrations were > 0.8 mmol/L, which would
be more clinically relevant for making treatment deci-
sions. In that further analysis, 37%, 48%, and 71% of
POC meter values were within 5%, 10%, and 20% of the
LBA values, respectively. Patterns were similar to those
of BHB for blood glucose concentrations as measured
with the POC meter, for which 11%, 23%, and 44% of
the POC meter glucose values were within 5%, 10%,
and 20% above or below the LBA values.
The Bland-Altman difference plot revealed that the
mean difference in BHB concentrations between de-
vices was small, with narrow limits of agreement (Fig-
ure 1). Visual examination of the plot revealed a small
negative constant bias in the BHB data and an increase
in data scatter as BHB concentration increased. Eleven
upper and 5 lower outlier values were identified, and
the blood samples to which these pertained had been
collected across multiple dates; however, 3 were from
the same collection date and 3 others were from the
same sheep over 3 weeks. When the plot was examined
by feeding group, a small positive bias was evident in
the data points for the group fed 50% of their nutri-
ent requirements from 28 through 78 dGA and a nega-
tive bias was identified in the data points for the group
fed 50% of their nutrient requirements from 28 dGA
through parturition. The difference plot for glucose
concentration showed a larger mean difference with
wide limits of agreement, negative constant bias, and
more scatter in the data than was evident for BHB (Fig-
ure 2). Twelve upper and 3 lower outliers were identi-
fied; 6 values pertained to blood samples collected on
the same day, and 3 values pertained to samples col-
lected on a day when severe hemolysis was noticed in 3
discarded samples. Outlier data points represented ap-
proximately 3% of the samples collected.
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Figure 2—Error grid analysis (A) and Bland-Altman plot (B) com-
paring blood glucose concentrations measured with a dual-pur-
pose POC meter with serum glucose concentrations measured
with an LBA in samples from pregnant mixed-breed ewes with
different feeding regimens. A—The error grid comprises 4 zones.
Zone A represents POC meter glucose concentrations within
20% of the LBA concentrations as well as when the POC con-
centration was ≤ 50 mg/dL when the LBA concentration was also
≤ 50 mg/dL. Zone B contains POC meter concentrations that
were > 20% of LBA concentrations but would result in a benign
treatment decision or no treatment decision. Zone C contained
POC meter glucose concentrations that would result in treating
a sheep when the LBA glucose concentration was within the
acceptable range, and zone D contained POC glucose concentra-
tions that would result in not treating a sheep when the LBA was
lower than the acceptable range. See Figure 1 for remainder of
key.
Modified error grid plots developed to hypotheti-
cally evaluate results of clinical decision making based
on use of the POC meter versus the LBA results showed
that 97% of BHB concentrations were within zones A
(93%) and B (4%), 2% were within zone C, and 1% was
within zone D (Figure 1). For glucose concentrations,
72% were within zones A (68%) and B (4%), 27% were
within zone C, and 1% was within zone D (Figure 2).
Discussion
The present study was conducted to evaluate the
performance of a dual-purpose POC meter for mea-
surement of blood BHB and glucose concentrations in 3
groups of sheep during gestation and lactation. The ma-
ternal malnutrition study from which they originated
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provided an opportunity to evaluate the POC meter in
various environmental conditions and ewe nutritional
states, which would be difficult to do in a nonexperi-
mental setting because most producers would inter-
vene to reduce the effects observed in these ewes.
The POC meter was more appropriate for measuring
blood BHB concentrations than blood glucose concentra-
tions in sheep. The results were poorer than those in a pre-
viously reported study,8 but the differences between stud-
ies may have been attributable to the larger sample size in
the present study, ewe metabolic effects from malnutrition
during gestation, environmental conditions, differences in
sample handling, statistical techniques, or LBAs used. An-
other explanation is potential variations between the POC
meters used, given that they are marketed with different
names depending on the country of origin.8 The LBA and
sample handling details were not described for the earlier
study,8 and blood samples in that study were obtained at
only 1 point during gestation or lactation. In addition, the
use of the Bland-Altman plots and error grid plots in the
study provided more clinically relevant results regarding
meter performance, compared with the other study.12–14
The precision of the POC meter was compared
with the manufacturer’s reported precision because we
were unable to identify any reports of studies in which
the meter had been evaluated. The CV was similar to
the manufacturer’s reported results.10,11 Glucose meter
performance criteria have been established by several
testing and health organizations and range from 5% to
20%.15 Similar criteria are not available for POC meter
performance when measuring blood BHB concentra-
tion. When used as a POC glucometer, the results for
the device did not meet the criteria established by the
testing organizations. This was not surprising because
the meter is manufactured for measurement of analytes
in human blood samples. The BHB performance results
were best when compared with the LBA results in a
more clinically relevant range (> 0.8 mmol/L) rather
than across the entire range. Some of the variation at
the lower ranges is likely attributable to reporting dif-
ferences, considering that the LBA results were provid-
ed to 2 decimal places, whereas the POC meter results
were provided to only 1 decimal place.
The Bland-Altman difference plots also showed
that the POC meter compared more favorably with the
LBA when used to measure BHB concentration rather
than glucose concentration. The systematic bias evi-
dent with both meters used could be addressed through
application of a correction factor to the results or es-
tablishment of meter-specific reference limits. However,
the significant proportional bias in the blood glucose
results would not be correctable. The increase in scatter
at higher BHB and glucose concentrations was likely
due to the smaller number of blood samples in these
ranges.
Modified error grid plots revealed that the POC
meter was clinically acceptable for use according to
our criteria for measuring blood BHB concentrations in
sheep, whereas the measurement function for glucose
concentrations was not acceptable. No differences were
observed in values between nutritional status groups for
either analyte. The plots were useful in identifying risk
for over- or undertreatment or inappropriate treatment
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 decisions. Use of the POC meter would result in a large
number of decisions resulting in overtreatment when
used to measure blood glucose concentrations. The risk
of overtreatment would not likely increase illness sever-
ity but would increase the cost to the producer because
low POC meter glucose concentrations would most
commonly lead to oral or parenteral administration of
glucose substrates to increase blood glucose concentra-
tion. Diagnosing hyperglycemia rather than normogly-
cemia would not likely result in different intervention
strategies because it would be difficult to identify the
cause of an isolated high glucose concentration. An in-
crease in blood glucose concentration can result from
stress induced by capture and blood collection, actual
meter characteristics, medical disorders, or typical in-
traindividual variation.
The POC meter was robust and easy to use in vari-
ous conditions; however, the low end of the operating
range of 10°C would prevent its use by producers and
veterinarians working with pregnant ewes in colder cli-
mates. We found that keeping the meter and test strips
in a small cooler with a chemical hand warmer main-
tained the proper operating temperature. Because of the
large number of samples tested at each time point, we
used 2 identical POC meters to reduce the need to re-
calibrate between BHB and glucose testing. One POC
meter would be adequate to measure both analytes in
most farm or veterinary settings.
The choice to evaluate the meters in various con-
ditions that many sheep producers would experience
resulted in many potential sources of variation in the
present study. Operator variables included differences
in sample collection and handling technique and risk
of test strip contamination from dirt, lanolin, blood, or
other factors. Despite the use of warming containers
for the meters and test strips, the temperature and en-
vironmental variations potentially could have affected
meter and strip performance. Multiple lots of test strips
were required, adding another potential source of varia-
tion in results. To reduce this variation, the meters were
calibrated prior to every collection day and before new
boxes of test strips were used. In addition, the expira-
tion date of the test strips was heeded and extra test
strips were stored in a climate-controlled environment
in their original packaging.
The ewes were not accustomed to being handled
nor confined, contributing to the difficulty in obtaining
blood samples and increasing the risk of hemolysis or
blood clots forming in samples prior to testing. Hemo-
lysis is easy to produce in sheep blood samples and is
known to increase serum glucose concentrations.16 The
study blood samples had various degrees of hemoly-
sis, which may have affected POC meter performance;
however, the effect of hemolysis on the results was not
evaluated.
Other factors such as anemia, hypertriglyceride-
mia, hyperproteinemia, handling technique, ambient
temperature, altitude, and pregnancy-induced blood
volume expansion could have also affected blood glu-
cose results obtained with the POC meter.17,18 The ef-
fects of these factors on blood glucose concentration
have not been evaluated in combination with gesta-
tional stage and fetal numbers in sheep. Hematocrit
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12-12-0397r.indd 1064
was not measured; however, an unreported preliminary
nutritional energy restriction study revealed no signifi-
cant effect on Hct in the sheep. All the ewes used in the
study were visibly examined for signs of anemia (pale
mucous membranes and sclera) during sample collec-
tion, and no gross evidence of anemia was observed;
however, the presence of mild anemia may have been
overlooked. Some serum samples had evidence of mild
to moderate lipemia, but there was no apparent rela-
tionship with nutritional status or gestational stage be-
cause concentrations would fluctuate among blood col-
lection points and sheep. Similar factors have not been
reported as affecting blood BHB concentration, and the
manufacturer reports that Hct, various medications,
and high triglycerides concentration do not affect BHB
results.10
The POC meter used in the present study was
designed for use in humans, in which blood glucose
is known to be distributed evenly between the RBCs
and plasma; however, in sheep, 83% of the glucose
is distributed in the plasma and the remainder in the
RBCs.19,20 Although glucose utilization by the RBCs
continues until the serum is separated from the cells,21
the low serum glucose concentrations observed in the
study sheep were surprising. Blood samples were kept
on ice to limit cell glucose utilization until the samples
could be centrifuged, and serum was removed from the
blood clot within 3 hours after collection. We identified
a significant difference in LBA-measured glucose con-
centrations between the control sheep fed 100% of their
nutrient requirements and those fed a restricted amount
(data not shown); however, serum glucose concentra-
tions in the control group were still quite lower than
the lower reference limit of our laboratory (70 mg/dL).
Given the study findings, the laboratory’s reference lim-
its for adult sheep may not be appropriate for pregnant
ewes. Our methods for sample collection and storage
after serum separation should not have dramatically al-
tered the blood glucose and BHB concentrations.16
The 3 groups of sheep that differed in nutritional
status were used to determine whether feed restriction
would sufficiently alter ewe metabolism to affect blood
glucose and BHB concentrations. No evidence of such
an alteration was observed; however, the feed-restricted
sheep had BHB and glucose results that would typically
require treatment intervention to prevent development
of pregnancy toxemia.
Overall, the dual-purpose POC meter appeared to
be adequate for measurement of blood BHB concentra-
tion in sheep and useful in the diagnosis of ketosis and
pregnancy toxemia. Its use could lead to earlier disease
detection and intervention as well as lower treatment
and management costs for producers. The meter was
not as reliable for measurement of blood glucose con-
centration. Therefore, glucose results should be inter-
preted with caution to avoid inappropriate medical
management of suspected hypoglycemic or hypergly-
cemic sheep.
a. Precision Xtra Blood Glucose & Ketone Monitoring System, Ab-
bott Diabetes Care, Abbott Park, Ill.
b. Grabber Hand Warmers, YSC Inc, Grand Rapids, Mich.
c. Serum Vacutainer glass blood collection tubes, Becton, Dickin-
son and Co, Franklin Lakes, NJ.
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 d. Roche Hitachi 917 Blood Chemistry Analyzer, Hitachi Ltd, To-
kyo, Japan.
e. MedCalc, version 12.3, MedCalc Software, Mariakerke,
Belgium.
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