Ketones and Diabetic ketoacidosis (DKA) University College Hospital

University College Hospital
Ketones and Diabetic
ketoacidosis (DKA)
Children and Young People’s Diabetes
Service
What are ketones?
When the body can't use glucose for energy, it uses fat instead. When fats are broken
down for energy, chemicals called ketones are produced
Ketones can be caused by two different mechanisms – when there is a shortage of food
(starvation ketones) and when there is not enough insulin (diabetes ketones).
Starvation ketones are caused by the body using its fat reserves for energy, instead of
carbohydrates. This fat is broken down by the body into fatty acids and glycerol. The
glycerol is changed into glucose and used for fuel for the body, and the fatty acids are
changed into ketones in the liver. Starvation ketones are produced when the blood
glucose level is low and develop more quickly in children than in adults. This process is
rectified as soon as carbohydrate is available, so the treatment is often to have
carbohydrate to eat/drink.
In contrast, ‘diabetes ketones’ are caused when there is sufficient carbohydrate but
insufficient insulin. This will mean that the carbohydrate cannot be used for fuel by the
body as it gets stuck in the bloodstream, outside of the cell. A high blood glucose level at
the same time as having ketones indicates that the body needs more insulin (in the form
of rapid acting insulin such as NovoRapid or Humalog Lispro). The extra insulin then
blocks the production of further ketones.
When you have ketones this is often called ketosis. People with ketosis may feel
nauseous, have stomach ache and may actually vomit. The breath may smell like nail
polish remover.

When are ketones dangerous?
Sometimes in people with diabetes ketones can build up to a dangerous level and this is
called diabetic ketoacidosis or DKA.
Several things have to go wrong to get to this state:
Blood glucose must be high
Insulin levels must be low
The body must be breaking down fat stores
High levels of glucose and ketones make the blood acid and make you urinate more often
leading to increased thirst.
Symptoms of DKA are:
Loss of appetite
Stomach ache
Blurred vision
Fever, flushed or warm
Difficulty breathing
Weakness and sleepiness
Smell of ketones on breath
Treatment for DKA needs:
Treatment in hospital
Fluids to reverse the dehydration
Insulin (via a drip) to force glucose into cells
Electrolytes such as sodium and potassium to replace those lost in the urine
See our ‘Sick day rules’ for advice on what action to take if you find your child has
ketones.
How to prevent DKA?
Take insulin regularly and adjust amount depending on your blood glucose and
ketone levels. Follow your sick-day rules.
Don’t stop taking insulin if you are unwell
Drink enough water to prevent dehydration
Don’t exercise if you have ketones
Call the Diabetes team for advice if you are concerned or unsure of what to do
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When to test for ketones?
Ketone testing lets you know what is happening and means you can get on top of the
problem quickly. Test for ketones when:
You are ill. Check blood glucose and ketones at least every 2-4 hours
You feel nauseated or actually vomit
You have 2 consecutive blood glucose levels >14 mmol/l
How to test?
There are two ways of detecting rising ketones. You can test your urine (measuring
acetoacetate) or your blood (measuring beta-hydroxybutyrate).
Ketones accumulate in your urine over several hours, so measuring them in urine cannot
tell you what your levels are right now. Testing your blood for ketones will allow you to
identify ketones earlier and will normalise sooner, following treatment. This helps prevent
later hypoglycaemia from over insulin treatment.
Contact Numbers:
Office Hours (8am – 6pm): 020 3447 9364 (Children’s Diabetes Nurses)
Out of Hours:
020 3456 7890 and page Paediatric On-call Registrar
Further information and fact sheets can be found on our Children and Young People’s
Diabetes web page at http://www.uclh.nhs.uk/
or by emailing us at childrensdiabetesnurses@uclh.nhs.uk
Expert advice and information about children and young people's type 1 diabetes at
www.uclh.nhs.uk/T1
If you need a large print, audio or translated copy of this document, please
contact us on 020 3447 9364. We will try our best to meet your needs.
First published: 19/07/13
Date last reviewed: 19/07/13
Date next review due: 19/07/15
Leaflet code: UCLH/SH/PAED/CYPDS/KETONES/1
© University College London Hospitals NHS Foundation Trust
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