Ketones....

[mauricekenter]

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So I have run across this multiple times now as a resident and I haven't found a solid answer yet (lots of different opinions). There have been many times in which I have admitted someone for a complaint like simple cellulitis and they also have a chemistry looking something like this.

Na 136
K 4.6
Cl 94
CO2 23
BUN 10
Cr 0.6
Glucose 362

So my questions is...what is the proper way to handle this to determine if they are in DKA? I've always played it as there is NO WAY they can be in DKA because their bicarb is 23 (even though the anion gap is 19), which means they are not in a metabolic acidosis -> diabetic ketosis, but no DKA. They could maybe develop this if untreated, but no need for ICU time, just give them IV fluids and sliding scale insulin.

However we have other residents on the floor that LOVE getting serum ketones. And of course they are moderate or large and now they are being admitted with DKA....which I still feel isn't true and can easily happen with other states like ARF or starvation ketosis.

Is my thought process correct? I am attempting to find the correct way to manage this and what proper tests need to be done (i.e.: serum ketones, serum Osm if BS is really high, VBG for pH, etc).

Thanks ahead of time, I'm just trying to not to be an ignorant slut.

 

[Apollyon]

"Ketotic nonacidotic" is the keystone of the Adkins diet. I unintentionally did Adkins before I was dx'd Type I DM. The simple presence of ketones does not make someone acidotic. A nonacidotic gap? 2/3 of those are from dehydration (other causes are carbenicillin - yeah, right - and a pure metabolic alkalosis).

Lies, damn lies, and statistics - that's what you got. Normal bicarb, you are not acidotic. Any questions, look at the blood - gases, that is. That's where is the money.

Wow - that is quite stilted, what I just wrote. Let me clean it up.

Your bicarb on your chem 7 - normal? Not acidotic. Question that? Look at the blood gases - the chemistry is calculated, but the blood gases are directly measured. Heavy ketone load can make a patient acidotic, but, presence of ketones alone is not diagnostic. Also, recall that ketones can test negative even in acidosis, because the beta-hydroxybutyrate is not detected (which is one of the 3 ketone bodies, along with acetone and acetoacetone, which the clinitest does detect). And a gap in a nonacidotic patient is, the majority of the time, dehydration, which is not difficult to consider in a hyperglycemic patient.

Does that help?

 

[pinipig523]

You can be in DKA but have near normal HCO3 if you are vomiting a lot and in fluid contraction 2/2 metabolic alkalosis.

You can also have this occur with heavy GI losses such as an ostomy.

 

[Apollyon]

You can be in DKA but have near normal HCO3 if you are vomiting a lot and in fluid contraction 2/2 metabolic alkalosis.

You can also have this occur with heavy GI losses such as an ostomy.

Acidotic? As I said, you have a non-acidotic gap with metabolic alkalosis and dehydration (from any cause). And alkalosis is not acidosis, and therefore not DKA.

To have DKA, the patient has to be acidotic, ipso facto. Where is your "near normal" bicarb - high or low? If it's a mixed acid/base disorder, and your bicarb is normal, then you chemically can't have an acidosis (Kussmaul's respiration?). If the pH is between 7.35 and 7.45, it doesn't matter the volume of ketone bodies, as long as the pH is not affected. That is the ketotic non-acidotic state.

 

[Rendar5]

only other thing to add is that a gap doesn't mean there are ketones. There are other negatively charged molecules that can exist in a gap such as lactate.

 

[mauricekenter]

Thanks for all the input guys! So here is what I'm basically understanding:

1) Getting serum ketones won't change my management
2) If the bicarb is normal then their is no way they can be in DKA, but if I'm not convinced I can check a gas for pH.

Apollyon, how do you handle situations like the one I presented above? For me, I'm basically done looking into DKA when the bicarb is normal and I don't draw serum ketones or an ABG for pH even if the patient has an anion gap (likely 2/2 dehydration).

When should I consider drawing a pH and can this be a VBG instead of an ABG?


Also I believe these patients are on a spectrum in their metabolic process. Just because they have a normal bicarb now, doesn't mean they won't have a low bicarb in a few hours if left untreated. However, if I treat their glucose with both fluids and insulin and let them eat to stave off starvation ketosis, then they will improve and not enter DKA a large majority of the time.

Thanks again!

 

[Smackey]

I start with the VBG in these patients. It come back in 3 minutes as our respiratory therapists do them and if they aren't acidotic then they are not in DKA. ABG is unhelpful in these patients as all you care about is the Ph. I have since stopped getting serum ketones and basically use VBG plus a Chem to decide.

 

[WilcoWorld]

You can be in DKA but have near normal HCO3 if you are vomiting a lot and in fluid contraction 2/2 metabolic alkalosis.

You can also have this occur with heavy GI losses such as an ostomy.

I agree, although it's rare to see DKA with a bicarb>21, it is possible if the patient has two competing primary metabolic processes. However, if there's no anion gap, then you can stop worrying about such exotic pathologies.

To measure pH VBG will work just as well as ABG. As far as I'm concerned, the only thing an ABG gives you that a VBG will not is arterial oxygenation.

So, if you're considering DKA in such a setting, calculate your anion gap.
If it's low --> stop worrying, if it's high --> check a VBG.

 

[WilcoWorld]

I have found this article to be immensely helpful with approaching acid-base disorders.

 

[pinipig523]

Acidotic? As I said, you have a non-acidotic gap with metabolic alkalosis and dehydration (from any cause). And alkalosis is not acidosis, and therefore not DKA.

To have DKA, the patient has to be acidotic, ipso facto. Where is your "near normal" bicarb - high or low? If it's a mixed acid/base disorder, and your bicarb is normal, then you chemically can't have an acidosis (Kussmaul's respiration?). If the pH is between 7.35 and 7.45, it doesn't matter the volume of ketone bodies, as long as the pH is not affected. That is the ketotic non-acidotic state.

I agree, although it's rare to see DKA with a bicarb>21, it is possible if the patient has two competing primary metabolic processes. However, if there's no anion gap, then you can stop worrying about such exotic pathologies.

To measure pH VBG will work just as well as ABG. As far as I'm concerned, the only thing an ABG gives you that a VBG will not is arterial oxygenation.

So, if you're considering DKA in such a setting, calculate your anion gap.
If it's low --> stop worrying, if it's high --> check a VBG.

^^^

That's what I was trying to get at.

You can be in DKA, be acidotic... but your bicarb can be elevated 2/2 a contraction metabolic alkalosis if you're vomiting or having exogenous GI losses.

That's all I'm saying.

 

[pinipig523]

I have found this article to be immensely helpful with approaching acid-base disorders.

My brain is fried right now and I can't read it.

But anytime I have an acid-base d/o patient, I go through these steps:

1. What is primary disorder (acidemic or alkalemic?)
2. Is it a primary respiratory or primary metabolic d/o?
3. I skip the acute vs chronic calculations - mainly because I can't remember it in my head.
4. If + met acidosis, then calculate WINTER'S FORMULA for resp compensation vs a concomitant respiratory condition existing?
5. Is there an anion gap?
6. Delta/delta calculation... IF AGMA exists, then is there also another metabolic disorder (non anion gap met acidosis vs metabolic alkalosis)?

I do it every time.

Formulas:
Winters = 1.5xMeasured HCO3 + 8 +/- 2 = pCO2 expected to compensate for that particular acidotic patient (and compare to the patient's measured pCO2)

AG = Na - Cl - HCO3

Delta/Delta = Delta AG + measured HCO3 = corrected HCO3. If your corrected HCO3 >28 then Metabolic Alkalosis also exists. If your corrected HCO3 < 20 then NAG Met Acidosis exists.

 

[WilcoWorld]

My brain is fried right now and I can't read it.

But anytime I have an acid-base d/o patient, I go through these steps:

1. What is primary disorder (acidemic or alkalemic?)
2. Is it a primary respiratory or primary metabolic d/o?
3. I skip the acute vs chronic calculations - mainly because I can't remember it in my head.
4. If + met acidosis, then calculate WINTER'S FORMULA for resp compensation vs a concomitant respiratory condition existing?
5. Is there an anion gap?
6. Delta/delta calculation... IF AGMA exists, then is there also another metabolic disorder (non anion gap met acidosis vs metabolic alkalosis)?

I do it every time.

Formulas:
Winters = 1.5xMeasured HCO3 + 8 +/- 2 = pCO2 expected to compensate for that particular acidotic patient (and compare to the patient's measured pCO2)

AG = Na - Cl - HCO3

Delta/Delta = Delta AG + measured HCO3 = corrected HCO3. If your corrected HCO3 >28 then Metabolic Alkalosis also exists. If your corrected HCO3 < 20 then NAG Met Acidosis exists.

I understand not being up to it right now, but give the article a look sometime. It's even simpler than the approach you describe (table 2 "Rules of Thumb...Without a Nomogram" has the meat, the rest is mostly the rationale), and it's highly unlikely to miss anything emergent.

 

[deleted109597]

Two things.
Corey Slovis has a pretty simple formula similar to that of the WJM article.
Who cares? I realize that we don't want to look stupid or lazy (think ortho) to our mentally masturbating flea friends, but in any given day in my ED, I think approximately 10 seconds about any patient not actively needing immediate resuscitation. The patients we are talking about here fit in that category. Just like the hyponatremics. If they aren't seizing, I don't care. Let someone with more time figure out the formula on how much fluid to give them. I just make sure to free water restrict them so the nurses don't keep giving them water cups.
Am I alone in that in the grand scheme of the ED, this matters little?

 

[Apollyon]

Two things.
Corey Slovis has a pretty simple formula similar to that of the WJM article.
Who cares? I realize that we don't want to look stupid or lazy (think ortho) to our mentally masturbating flea friends, but in any given day in my ED, I think approximately 10 seconds about any patient not actively needing immediate resuscitation. The patients we are talking about here fit in that category. Just like the hyponatremics. If they aren't seizing, I don't care. Let someone with more time figure out the formula on how much fluid to give them. I just make sure to free water restrict them so the nurses don't keep giving them water cups.
Am I alone in that in the grand scheme of the ED, this matters little?

No, you're not. Remember, we're like golfers, but we just have to get on the green. The diabetics are exactly that. We don't have to 3 or 4 or 5 putt to hole out - that's someone else's job. The hyponatremics are the same. I used to do the Winter's formula when I was a resident - not anymore.

Normal bicarb? Not DKA. Fluids either way you look at it. Ketones? Whatever.

 

[pinipig523]

I understand not being up to it right now, but give the article a look sometime. It's even simpler than the approach you describe (table 2 "Rules of Thumb...Without a Nomogram" has the meat, the rest is mostly the rationale), and it's highly unlikely to miss anything emergent.

Really - I'll take a look at it.

It's pretty easy for me to run through a set of numbers. The AG is usually already given on the BMP.

All I do is look at the pH, look at the hco3, look at the AG. Then I see if there's a quick delta delta. Then I do Winters. Done. Probably no more than 20 seconds.

But if the article is even quicker, I'll check it out for sure.

 

[mauricekenter]

Thanks for all the input so far.

I'm a resident in a VERY community setting with lots of poorly controlled diabetics. For me it changes my decision on either admission to ICU versus floor versus discharge. I see lots of people with sugars in the 300s, 400s, 500s, 600s+ and I'm always running through my DKA vs HHNK vs hyperglycemia and I just need to give some fluids, a little insulin and send home. (most of their complaints are "high sugar" or "not feeling well" or I even had a lady yesterday with a sugar of 644 and she was there because she fell getting off the bus and hurt her knee and the triage doc wanted to check a BMP for some reason or another).

So this comes into play greatly for me when I need to decide if this person is an ICU admission versus floor versus going home. Maybe I am approaching it wrong, but this is the usual scenario...

Simple "not feeling well complaint" and their sugar is 400 with a bicarb > 18. I give a liter of NS, sometimes 5 units of insulin IV and get it < 400 and then send home and tell them to control their sugars better/give them syringes or insulin if they ran out. However, if they need to be admitted for another complaint and I had the exact same labs, I call the floor doc and they ask...why is the anion gap 17 and I say "not sure, they aren't in DKA." So they come down, draw ketones, they turn out to be moderate and now this same guy is getting admitted to the ICU for DKA when I would have just sent them home if they never had admission criteria for another reason.

I just want to make sure I'm not sending people home who need to be admitted to the ICU for DKA (if you follow the diagnostic criteria, they cannot have DKA with a bicarb > 18, so this is the rule I have always used). However, if you read the above article mentioned it seems to state that if you have an anion gap > 20 even with a normal bicarb, then they have a mixed acid-base status which must include a metabolic acidosis...so now what?

 

[Apollyon]

I just want to make sure I'm not sending people home who need to be admitted to the ICU for DKA (if you follow the diagnostic criteria, they cannot have DKA with a bicarb > 18, so this is the rule I have always used). However, if you read the above article mentioned it seems to state that if you have an anion gap > 20 even with a normal bicarb, then they have a mixed acid-base status which must include a metabolic acidosis...so now what?

Although there is truth in the article, it is 21 years old, and I dare say we've evolved in our thought. That article states that, if the gap is >= 20mmol/L, "then a metabolic acidosis is present regardless of the pH or serum bicarbonate concentration". I do not buy that. But that's where the art of medicine kicks in; if the patient looks sick, you can easily drop that gem on the admitting team, and let them wrangle with it. Also, you could call nephro for an opinion; they're all about acid/base. If the pt does not appear ill, is not tachypneic, and does not have an acidosis, how likely is it that the pt has a mixed disorder, and has a metabolic dyscrasia, but is not manifesting it?

And, if simply hydrating the patient closes the gap, are they really this acid/base nightmare?

Back when I was a resident, the difference between DKA and non-DKA hyperglycemic insulin dosing was fourfold (0.1unit/kg/hr vs 0.025unit/kg/hr), so it does make a difference.

This is where you talk to the patient: "Your blood sugar is high, and the blood tests we did do not look good, but you DO look good. That's why it is not clear right this second if we have to admit you. We're going to give you some IV fluids (+/- insulin), and recheck your blood. If it is improving, then we're good. However, if you blood gets worse, or YOU do, we'll have to admit you."

 

[xaelia]

Really? No one manages their DKA with SQ insulin?

http://care.diabetesjournals.org/content/27/8/1873

(OK, yeah, neither do I - since I'm not doing the managing, just the admitting part)

For non-DKA hyperglycemia - make them (relative) euvolemic, correct any metabolic derangements, identify the exacerbating etiology, and may the wind be at your back. The serum glucose level at discharge for the routine uncontrolled diabetic doesn't interest me - it's not some hyperviscosity syndrome that needs emergent glucopheresis. My residency had us get the glucose under 300 for discharge using IV insulin - pointless.

 

[WilcoWorld]

Although there is truth in the article, it is 21 years old, and I dare say we've evolved in our thought.

Have Winter's formula, the Henderson-Hasselbalch equation or the principles of compensatory mechanisms actually evolved in the last 21 years?

 

[Apollyon]

Have Winter's formula, the Henderson-Hasselbalch equation or the principles of compensatory mechanisms actually evolved in the last 21 years?

Although there is truth in the article, it is 21 years old, and I dare say we've evolved in our thought.

You are simply trying to be argumentative. I posted above that I used to do the Winter's formula myself on these patients. Compensatory mechanisms have not changed. However, as I quoted, the statement that a metabolic acidosis exists irrespective of pH and bicarb levels is out of date. Which I stated. Which is researchable - a non-acidotic gap has the most likely etiology of dehydration (about 2/3).

Or did you just look for one line to break out your snark? Or did you miss the part where I wrote "Although there is truth in the article" - to be honest, I can't interpret that as discounting Winter's formula or the Henderson-Hasselbalch equation. Or do you agree that a non-acidotic patient with an anion gap has an acidosis, irrespective of pH? Taken by itself, that line is nonsensical. Or do you object that I say we've evolved past that?

Or what WAS your purpose in posting your comment? I seem to have missed it. Or maybe you have a beef with me (really? Really?) Yes, really.

 

[pinipig523]

Thanks for all the input so far.

I'm a resident in a VERY community setting with lots of poorly controlled diabetics. For me it changes my decision on either admission to ICU versus floor versus discharge. I see lots of people with sugars in the 300s, 400s, 500s, 600s+ and I'm always running through my DKA vs HHNK vs hyperglycemia and I just need to give some fluids, a little insulin and send home. (most of their complaints are "high sugar" or "not feeling well" or I even had a lady yesterday with a sugar of 644 and she was there because she fell getting off the bus and hurt her knee and the triage doc wanted to check a BMP for some reason or another).

So this comes into play greatly for me when I need to decide if this person is an ICU admission versus floor versus going home. Maybe I am approaching it wrong, but this is the usual scenario...

Simple "not feeling well complaint" and their sugar is 400 with a bicarb > 18. I give a liter of NS, sometimes 5 units of insulin IV and get it < 400 and then send home and tell them to control their sugars better/give them syringes or insulin if they ran out. However, if they need to be admitted for another complaint and I had the exact same labs, I call the floor doc and they ask...why is the anion gap 17 and I say "not sure, they aren't in DKA." So they come down, draw ketones, they turn out to be moderate and now this same guy is getting admitted to the ICU for DKA when I would have just sent them home if they never had admission criteria for another reason.

I just want to make sure I'm not sending people home who need to be admitted to the ICU for DKA (if you follow the diagnostic criteria, they cannot have DKA with a bicarb > 18, so this is the rule I have always used). However, if you read the above article mentioned it seems to state that if you have an anion gap > 20 even with a normal bicarb, then they have a mixed acid-base status which must include a metabolic acidosis...so now what?

Read my post - and start practicing the calculations on patients. Soon you'll understand the mechanisms going on. Once you pick it up, you'll be more like Apollyon and not have to do the calcs on everyone.

That said, if there is an AG - there's something wrong or something you're missing.

If the patient is hyperglycemic with a mild drop in their hco3 (but >20) and no gap... it doesn't matter if ua is ketone positive - it's probably just hyperglycemia. IVF, a shot of sq insulin, and home.

But don't forget the pesky HHS. They can have near normal pH (> 7.3), a variable AG (could be normal), a HCO3 of >18.... make sure you know when to pick it up. I.e. >600 glue + >320 serum osm calculated.

 

[WilcoWorld]

Although there is truth in the article, it is 21 years old, and I dare say we've evolved in our thought.

You are simply trying to be argumentative. I posted above that I used to do the Winter's formula myself on these patients. Compensatory mechanisms have not changed. However, as I quoted, the statement that a metabolic acidosis exists irrespective of pH and bicarb levels is out of date. Which I stated. Which is researchable - a non-acidotic gap has the most likely etiology of dehydration (about 2/3).

Or did you just look for one line to break out your snark? Or did you miss the part where I wrote "Although there is truth in the article" - to be honest, I can't interpret that as discounting Winter's formula or the Henderson-Hasselbalch equation. Or do you agree that a non-acidotic patient with an anion gap has an acidosis, irrespective of pH? Taken by itself, that line is nonsensical. Or do you object that I say we've evolved past that?

Or what WAS your purpose in posting your comment? I seem to have missed it. Or maybe you have a beef with me (really? Really?) Yes, really.

My point is that being 21 years old is not actually a valid criticism of an article. New data that conflicts the article's findings is a valid criticism, however, so I was asking if any existed.

I do not intend to respond to your assertion that I am "simply trying to be argumentative", for I see little potential that an increased understanding will come from engaging you on this issue.

 

[Apollyon]

My point is that being 21 years old is not actually a valid criticism of an article. New data that conflicts the article's findings is a valid criticism, however, so I was asking if any existed.

No, you didn't. You specifically asked a question that you assuredly knew 1. the answer and 2. was clearly set out in science, and did NOT address the balance of what I'd written in my post (such as I did not agree with that statement). You are trying to sound academic when you were just being argumentative. You did NOT make your point of your belief that the age of the article was not a valid criticism.

I do not intend to respond to your assertion that I am "simply trying to be argumentative", for I see little potential that an increased understanding will come from engaging you on this issue.

You really, really have an issue with this, don't you? Your ivory tower statement that I can't change my opinion is, not strangely, echoic of another thread, where you obliquely insulted me. Don't be passive-aggressive (which you are with these posts) - be aggressive-aggressive and gut up and tell me I suck, AND why. You're already in it - don't try to sound like you are "above the fray". You chose your words - and you chose wrongly. Unless, from your learned hand, you can construe an increased understanding of your just wanting to be intentionally contentious, because that's all you are - there is not a higher purpose.

Or, just argue the facts, and tell me I'm wrong by stating that a non-acidotic gap is most likely dehydration, and why - unless you would prefer just to be snarky. If you want to argue the facts, I'm all ears. If you just want to say I'm wrong, just keep walking.

 

[WilcoWorld]

No, you didn't. You specifically asked a question that you assuredly knew 1. the answer and 2. was clearly set out in science, and did NOT address the balance of what I'd written in my post (such as I did not agree with that statement). You are trying to sound academic when you were just being argumentative. You did NOT make your point of your belief that the age of the article was not a valid criticism.



You really, really have an issue with this, don't you? Your ivory tower statement that I can't change my opinion is, not strangely, echoic of another thread, where you obliquely insulted me. Don't be passive-aggressive (which you are with these posts) - be aggressive-aggressive and gut up and tell me I suck, AND why. You're already in it - don't try to sound like you are "above the fray". You chose your words - and you chose wrongly. Unless, from your learned hand, you can construe an increased understanding of your just wanting to be intentionally contentious, because that's all you are - there is not a higher purpose.

Or, just argue the facts, and tell me I'm wrong by stating that a non-acidotic gap is most likely dehydration, and why - unless you would prefer just to be snarky. If you want to argue the facts, I'm all ears. If you just want to say I'm wrong, just keep walking.

Fine Apollyon. I don't like to argue with you because I think you take comments out of context, use invalid arguments but try to make them sound good by using latin/quotes/polysyllabic words (often incorrectly) and you seem to criticize posters for sport rather than to reach a mutual understanding. I have tried to have civil disagreements with you previously, but you will often accuse me of something (like being too academic when we're having an academic discussion or caring too much about grammar when grammar is being discussed) such that any attempt to counter your claim will make me look silly. So, it's not that I'm passive aggressive. It's that I've found arguments with you to be unproductive.

Lastly, I never said that dehydration wont cause non-acidotic anion gaps - I'm not sure why you are making that claim.

 

[Apollyon]

Fine Apollyon. I don't like to argue with you because I think you take comments out of context, use invalid arguments but try to make them sound good by using latin/quotes/polysyllabic words (often incorrectly) and you seem to criticize posters for sport rather than to reach a mutual understanding. I have tried to have civil disagreements with you previously, but you will often accuse me of something (like being too academic when we're having an academic discussion or caring too much about grammar when grammar is being discussed) such that any attempt to counter your claim will make me look silly. So, it's not that I'm passive aggressive. It's that I've found arguments with you to be unproductive.

Lastly, I never said that dehydration wont cause non-acidotic anion gaps - I'm not sure why you are making that claim.

As I am always honest, I would like to have known when I used "latin/quotes/polysyllabic words (often incorrectly)"; I assure you that you are wrong. If my assurance is wrong, I would freely declare it (most recently, I clearly, cleanly admitted I was wrong about the volume of the Tripler Army Medical Center ED in Honolulu, HI). If I misquoted, I would appreciate knowing it. If my Latin isn't correct, I would like to know that. Likewise, if I am using words incorrectly, I would certainly want to know that. (There is a reason why.)

"Irony" is your statement about me taking comments out of context (that is, that is exactly what you did in this case.)

However, equally honestly, I do not recall any discussion/argument with you. I can't think of anything you've posted (or, at least, ascribe it to you). Maybe it's because you don't have an avatar, but I have not attributed anything to your account. Even though there are others without avatars whose postings I recall, whether for making persuasive, amusing, insightful, or specious arguments (the "notable and notorious"), I can't bring to mind anything else you've posted.

That you would think I make sport of others is flatly false.

As for dehydration et. al., you didn't say anything. You just made your snarky remark, and I stated what was one of my points. You still continue not to address that. That's what I said.