Ketones are metabolic byproducts of fatty acid metabolism. In the diabetic patient, the presence of ketones in the blood are indicative of a state known as diabetic ketoacidosis, or DKA, whereby there is an uncontrolled increase in blood glucose, total body ketone concentrations and metabolic acidosis. Very often, DKA appears as the abrupt onset of type 1 diabetes, leading to its diagnosis, and it is the most serious acute complication associated with diabetes. Early recognition of high ketones is essential to the treatment and avoidance of death.
Fruity-Smelling Breath
Acetone is one of two ketone bodies that are produced when insulin is not available in sufficient amounts to allow glucose to enter the cell for energy production. To substitute glucose, fat will be broken down by a process called lipolysis to provide the cells with the needed glucose and the left over ketone bodies are excreted in the urine. However, in the diabetic individual in DKA, ketone levels are too high for the kidneys to properly filter. As a result, excessive buildup of this particular ketone will give the breath of the individual in DKA a distinct fruity odor.
Beta hydroxybutyrate is the other ketone body that is found in DKA. Of the two ketone bodies, beta hydroxybutyrate is the most predominant however it does not give any physical sign of production like acetone. Since it is the most predominant ketone body produced in DKA, the medical staff will measure this particular acid to monitor the progression of treatment.
Deep, Rapid Breathing
Due to the elevation of ketone bodies in the blood, the blood becomes acidic. At a certain point when the arterial pH of blood becomes too low, life is not sustainable. In an effort to correct this metabolic acidosis, the body begins deep and rapid breathing that closely resembles the effort needed during exercise. This very distinct breathing pattern is called Kussmaul respirations, and it is a clear sign that an individual has elevated ketones and is in DKA.
Physical Signs
High ketones will accompany high blood sugar when insulin is insufficient to promote normal metabolism. When blood sugar is elevated beyond 250 mg/dL in the type 1 diabetic, measurement of ketones is recommended. In addition to elevated blood sugar, the classic clinical picture of DKA includes presentation with a history of increased urination, drinking water, weight loss, vomiting, weakness and mental status changes that can range from the mildly confused to full coma.
Treatment and Prevention of Ketones in Diabetes
After prompt diagnosis treatment of DKA will include rehydration, insulin therapy and replacement of potassium, phosphate, and bicarbonate if indicated. Self-care management of type-1 diabetes is essential to healthy living, and this is especially true during "sick days." When the body is fighting sickness, insulin requirements will be momentarily higher due to increased metabolic demand. DKA will result when the demand for insulin is not adequately met, so appropriate sick day management will include increased blood glucose monitoring and intensified insulin therapy to keep blood glucose levels within acceptable ranges. Prompt, open communication with the healthcare team is also recommended to help guide intensified insulin therapy and for any additional instructions for DKA prevention. It is also very important for the diabetic individual to stay well hydrated with liquids containing carbohydrates and electrolytes, especially if vomiting is present, at which point hospitalization may be recommended.
References
- "Diabetes Care," Hyperglycemic Crises in Adults Patients with Diabetes; Abbas E. Kitabchi et al.; December 2006
- "The Art and Science of Diabetes Self-Management Education," Hyperglycemia; The American Association of Diabetes Educators; 2006
