Because Ketone strips don’t come with built in algorithms that dictate “how much extra” insulin you should give your child based on the level of ketones in their system.
Blood ketone strips do come with “sick day plans” based on the numbers. X% more if ketones are between 0.5 and 0.8, Y% more if ketones are between 0.8 and 1.5, Z% for greater than 1.5, etc. They came with our insulin management plan home from the hospital after diagnosis. Obviously it’s not an exact science but it really really does shorten the decision tree process for us. WE’re aggressive with highs but the amount of insulin you need for ketones can be unreal. It really just gives you a huge headstart to know what you’re dealing wtih.
Also, you need to KEEP EATING with ketones, which you don’t necessarily do when you’re high without ketones. So you need X% more insulin for the ketones, plus Y% more for the extra carbs that will help clear them out.
My understanding is drinking/urinating is what flushes the ketones out of the system. This is the first time I’ve heard eat with high bgs while you have ketones.
nope, it’s not just fluids. You often also need to eat to clear ketones. Ketones are produced when the body uses its starvation metabolic pathway, in part. So eating carbs and then using a ton more insulin to kickstart carb metabolism can speed their clearance.
I knew how they were produced, but didn’t think about “more food” providing them a pathway. Makes sense, though! I always just have Liam drink plenty of water and urinate a lot if his BG’s are high (again, assuming BGs). Him eating while he’s high seems counterintuitive and could lead to EVEN HIGHER BG’s…but your explanation for why food could be used makes sense.
For me, I think the ‘least complicated and easiest managed’ method is to just give water and insulin until he comes back down.
I know I’m in the minority here but I think the risk (danger) of DKA is vastly overstated and the causes (and prevention) significantly misunderstood.
I say this after being insulin dependant T1D for 55 years and spending nearly an entire year in Ketosis.
It’s my goal to wake up with ketones in the 1.0-3.0 mmol/L range every day, and when I do extended fasts (48-72 hours) I aim to get my ketones up to 5 or higher (with lower BG this allows a GKI of 1.0 or under)
Worried about your ketones rising too fast or being too high (well over 10.0 mmol/L)? Insulin will always throw the brakes onto ketosis or DKA.
As long as you’re well controlled (i.e. Pump + CGM + BG and Ketone meters) it’s much easier for a T1D to maintain ketosis (ketone levels) than it is for a non-diabetic
Right at the beginning I had a bottle of 50 small tablets (not the big glucose test ones) on which I could deposit a drop of one of my bodies precious fluids (the golden one) and it would turn blueish if it got a whiff of acetone.
Many years later I learned I could breathe in the general direction of my wife and she could tell me, but I’m a T1D so I never ate pear drops. These days I have an alert called “ketone” set at 250mg/dl and I have tested it against probably fairly accurate test strips and it is perfect; no false positives, no false negatives.
In all my T1D life (49 years) I’ve not checked for ketones more than 10 times, mostly recently while verifying the Dexcom G6. It’s like walking into the middle of the interstate then checking for oncoming traffic.
I would just like to say that being a parent of a Type 1 is like having a full time job. Thank goodness for the technology in treating has come so far since I was diagnosed. I have been Type 1 for 53 years and only had Ketones in urine 1 time that I know of. I did have a stomach flu and was very sick. This incident was probably 25 years ago and family took me to ER. I do remember getting a few IV bags and probably extra insulin and was released same day. I am not on pump…just started Dexcom G6 and I do keep Ketone Stix close by just in case. I feel like being able to see my numbers now is a blessing. I only drink water with electrolytes and 1 cup coffee in the am. I truly believe that drinking as much water as I do truly helps. God Bless all and especially parents of children diagnosed…it breaks my heart!
I think the risk (danger) of DKA is vastly overstated and the causes (and prevention) significantly misunderstood.
I completely disagree with the first part of this sentiment for people in the younger ages. At your age, that might actually be the case; I found this paper showing that DKA+hypoglycemia account for n early HALF of all deaths for kids under 10, but a negligible number of deaths for people who are in the 55+ cohort.
But I do agree that we don’t fully understand the full mechanisms underlying DKA. I’m hoping that as people begin using SGLT-2 inhibitors more, which seem to kick off DKA even in the presence of normal blood sugars, we might begin to get a clearer picture.
Also, I have to say I think your advice about just using insulin to put the brakes on ketosis at high levels might be fine for a person who is healthy and in a normal situation day to day. You’re n a keto diet, so clearly you’ll have elevated ketones all the time. People who exercise a lot might also encounter ketones more frequently.
But the more typical situation is a person doesn’t usually run ketones, and is doing so all of a sudden in conjunction with high blood sugar and symptoms of illness – whether those are dehydration, nausea, flu, whatever. And in that case, just “slap some insulin on it” is not sufficient advice, as they may need electrolytes, fluids, and other things to stabilize the situation.
My guess is that the combination of ketones + some dehydration and other electrolyte imbalances are much worse than just elevated ketones on their own. And for most people, elevated ketones are also as sign that some of that other stuff might be going on.
A read this awhile back by Will Dubois and made me stop and think. As a long time diabetic and someone who has never been in DKA, I need to remember DKA can happen, even to me.
Has been an interesting discussion and I can see all sides. We test for ketones, but in my experience, the only time the information has been clinically helpful is when Cody was low and had extremely high ketones and his blood sugar kept cratering and we couldn’t give him enough insulin to get rid of the ketones and couldn’t keep his blood sugar up, it was really not a good time and was when we almost gave him glucagon to get his blood sugar up high enough to give the insulin to deal with the ketones. Fortunately we were able to get him to keep enough pedialyte and Gatoraide down to deal with it, but it was scary for awhile.
Tia (and other parents of T1 children) - I completely understand how concerned you are about your child’s health, especially BG and possible Ketone levels. I respect your judgement and admire all of you (I was on the other end as a diabetic child when there was nothing in the way of monitoring available for my parents).
That said, I stand by my opinions, and as I said at the outset,
As far as I know, I’ve never experienced DKA. I had a horrible incident in my early 20s where I stupidly checked my insulin in my luggage. It was a stupid mistake, and I know that. I hadn’t traveled alone much, and I just made a mistake.
While on a layover in Columbus Ohio, I accidentally pulled out my pump site (at a time when I already needed to bolus). I asked the airline if they could retrieve my luggage, and they said they couldn’t and called 911. All I knew was that I needed insulin right away, so I went to the hospital.
All of that stuff was my fault, but the hospital made everything soooo much worse. They wouldn’t give me insulin because they wanted to check for DKA first. They said they needed to treat me differently if I was in DKA. The test took hours and hours. By the time they did the test and got results, my bg level was higher than it’d ever been- even at diagnosis.
The doctor said I still wasn’t in DKA though. They could easily administer insulin- like they should have when I first got there.
I’m sure it’s a major concern for some people, but I don’t really understand what triggers it.
Now I’d do so many things differently- such as escape to Walmart and pick up R. I’m
convinced that everyone in Columbus must just die iif they need to go to the hospital.
I stand by what I feel about Ketones also. Testing Ketones won’t change my treatment plan so they’re not worth the effort of doing them UNLESS he’s been super high for a really long time (250+ for hours and hours). My treatment WITHOUT ketone test = my treatment WITH ketone test…so the only difference is that extra step and some knowledge that will probably not benefit me now or later. He’s got ketones. Great…insulin to the rescue.
Maybe it should be a bigger deal to me. ::shrug:: I just don’t get it. If the treatment plan was different, sure…but it’s not - at least not in my case. I’m always treating aggressively and the “level of ketones” in his system will only tell me to do more of what I’m already doing…treating very aggressively, changing PODs, giving lots of water, urinating a lot, not running around when excessively high, giving MDI if necessary, etc., etc.,
I guess I’m just not one of those people who has to have knowledge just for knowledge’s sake…there has to be some underlying reason behind it for me to be interested. But I WILL teach Liam about Ketones, DKA, etc., though, when he’s old enough…and express all of this being important FOR HIM to understand in case he wants to do this himself (or if he wants me to start doing it more regularly).
Having almost died from DKA when I was 18 and had salmonella, despite never ever running ketones even when experiencing extended highs normally, I’d say that testing for ketones for many folks is generally not necessary; however, having the supplies to do it is essential, because if a person is really sick, especially if they can’t eat, and running anything but perfect blood sugars, you should be monitoring ketones. Those factors (sickness, reduced insulin doses from not eating, dehydration) means DKA can happen way more easily than normal. If it starts to happen, you want to get IV fluids/electrolytes and IV insulin and glucose (glucose may be necessary to be able to pump in enough insulin when that sick), because it can be hard to get it sorted out, and it is miserable and organ damage can happen in the meantime. So basically, I don’t ever test for them, but I would if I was ever that sick again (bad food poisoning, noro virus, etc).
I think of it in a “number needed to treat” way. The number of ketone checks you need to do to prevent one case of DKA is probably in the hundreds, thousands or even tens of thousands for some people (depending on how prone to DKA you might be – which you won’t know until it happens, basically).
So the vast number of ketone checks are unnecessary. And most people who do ketone checks might never avert a case of DKA.
But the ketone check that IS necessary can save you a lot, and if you’re not doing all the unnecessary ones you raise the odds that you’ll miss that one which is necessary.
People use faulty logic with ketones: Because I’ve never had ketones, I’m not susceptible and I never will. Or: Because insulin is the answer, it doesn’t matter if I have ketones. (Again, sorting out insulin, electrolytes, ketones can be really complicated, it’s not just a matter of throwing insulin at the problem.)
Ironically, people who check ketones regularly might also not know when they’ve averted a case of DKA because they’re catching things so early it never feels like an emergency.
To me, it’s just such a low-stakes thing to do, and getting into the habit of doing it means that a) you’ll have the strips on hand when you need them an b) your ketone meter will work when you need it to. I’m a member of a local listserv and every few months we have a scary near-DKA or DKA story and the moral the parents always relay is “check ketones, DKA can happen fast” (along with other things like check your sites, don’t leave your insulin out in high heat, teach your kids emergency pump management protocols, etc.)
Also it’s worth pointing out again, that the most dangerous ketones happen when you have a stomach illness such that you can’t eat (and possibly can’t drink vast quantities effectively either, or are losing more water than you’re taking in), your blood sugars are not that high, and you need to slam insulin because of the infection but can’t for fear of going low, and the combination of illness and ketosis have caused dehydration and electrolyte imbalance. Insulin alone will not be the answer to that, and blood sugars alone may not be sufficient indicator that something is very wrong.
This is why although colds and flus are not fun as diabetics, my main concern re: getting sick is stomach/GI bugs. That said, if I ever have a severe one for an extended period of time again, I’m not waiting to have significant ketones to go get an IV anyway.
We’ll have to agree to disagree here. But no one said “throwing insulin at the problem is the answer.” In my response to how we deal with ANY high (ketone or not), I listed a whole slew of things we do in addition to insulin. Ironically, those things WE do are the SAME things you do. The only difference is that you also checked ketones, annotated that into your knowledge banks and really made no different decisions than I did after finding out that info. I know ketones are important as they can lead to DKA. What’s important in my opinion is recognizing symptoms and having sticks on hand if you need to use them.
But again, we can go back and forth all day on this but my logic is perfectly sound to me and quite a few others. You like to do lots of Ketone checks and I respect that. I find no immediate value in them so I just don’t do them - your diabetes treatment is exactly the same as mine for the most part when treating highs.
But I do know about DKA. I’m just kind of nonchalant about it. Perhaps I trivialize the risk too much.
I know ketones are important as they can lead to DKA. What’s important in my opinion is recognizing symptoms and having sticks on hand if you need to use them.