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 Table of Contents  
EDITORIAL
Year : 2020  |  Volume : 7  |  Issue : 6  |  Page : 305-306

Point-of-care capillary ketone testing for diabetic ketoacidosis: A step to the future


1 Department of Pediatric Intensive Care, Kokilaben Dhirubai Ambani Hospital, Mumbai, Maharashtra, India
2 Department of Pediatric Intensive care, SRCC Children's Hospital, Mumbai, Maharashtra, India

Date of Submission07-Sep-2020
Date of Acceptance14-Sep-2020
Date of Web Publication11-Nov-2020

Correspondence Address:
Dr. Vinay H Joshi
Department of Pediatric Intensive Care, Kokilaben Dhirubai Ambani Hospital, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcc.jpcc_161_20

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How to cite this article:
Joshi P, Joshi VH. Point-of-care capillary ketone testing for diabetic ketoacidosis: A step to the future. J Pediatr Crit Care 2020;7:305-6

How to cite this URL:
Joshi P, Joshi VH. Point-of-care capillary ketone testing for diabetic ketoacidosis: A step to the future. J Pediatr Crit Care [serial online] 2020 [cited 2020 Nov 27];7:305-6. Available from: http://www.jpcc.org.in/text.asp?2020/7/6/305/300586



Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes, characterized by a triad of hyperglycemia, ketonemia, and metabolic acidosis.[1],[2],[3] It is the most common metabolic emergency in children. It is precipitated by absolute or relative deficiency of insulin, leading to failure of normal glucose metabolism. The lack of insulin triggers the secretion of counter-regulatory hormones including catecholamines, glucagon, and cortisol. The hormonal imbalance triggers gluconeogenesis, glycogenolysis, and increased lipolysis. This leads to metabolic abnormalities of hyperglycemia and ketonemia. Unregulated lipolysis leads to production of large quantities of ketone bodies (acetoacetate, beta-hydroxybutyrate [BHOB], and acetone) and subsequent metabolic acidosis. Acetoacetate formed gets converted into BHOB, leading to increased acetoacetate-to-BHOB ratio (normal ratio 1:1).[3] In DKA, this ratio increases to 3:1, sometimes reaching up to 10:1.[4],[5] BHOB contributes to 75% of the total plasma ketone bodies. Normal values are <0.6 mmol/L, while values above 1 mmol/L and 3 mmol/L represent hyperketonemia and ketoacidosis, respectively.[6]

The diagnosis of DKA can be made by the clinical presentation of polydipsia, polyuria, lethargy, abdominal pain, nausea, vomiting, abnormal breathing, and altered sensorium. The diagnosis is confirmed by blood (blood sugar, ketones, and blood gas analysis) and urine (sugar and ketones) investigations. Urine ketones are measured by dipstick which is a semi-quantitative method based on nitroprusside test which changes the color of the ketone strip to purple violet.[7]

Using the dipstick method of measurement of ketones, being nitroprusside-based test, has limitations such as: it measures acetoacetate rather than BHOB which gets converted into acetoacetate and is continuously excreted, thus being detected even after DKA is resolved, leading to unnecessarily prolonged insulin infusion. It is impossible to collect urine in sick patients with oliguria or anuria. Hence, measurement of serum BHOB is more prudent for the diagnosis and management of DKA. Measurement of serum BHOB is more cumbersome and has a longer turnaround time, so point-of-care, capillary blood BHOB probably offers advantages. It is proven that the capillary measurement of BHOB is a validated method to compare serum ketones.[8],[9],[10]

The study by Shahzad et al.,[11] published in the current issue of the Journal of Pediatric critical Care, has assessed the clinical and statistical correlation of capillary measurement of BHOB with standard markers of acidosis in DKA. In their retrospective study, the authors studied the clinical and statistical correlation between capillary BHOB with other markers of DKA such as pH, HCO3, anion gap, and base deficit, from the time of diagnosis to the resolution of DKA. The diagnosis of DKA was made when capillary BHOB values were >3 mmol/L. All the patients received standard protocol treatment for DKA. Capillary blood BHOB was measured along with blood glucose from the same skin prick at the time of diagnosis and 4–6 hourly until the resolution of DKA. They found overall no statistical correlation between capillary BHOB and markers of acidosis at the time of diagnosis and resolution of ketosis (except HCO3 and base deficit on admission). However, they observed a positive correlation of BHOB measurement with clinical resolution of DKA.

The positive correlation of capillary BHOB levels and traditional ketoacidosis markers has been shown in many studies. Naunheim et al.[12] and Charles et al.[13] found that a capillary BHOB value of >1.5 mmol/L had an excellent sensitivity (100%) and specificity (93.3%) of detecting hyperketonemia, whereas capillary BHOB value >3.5 mmol/L had a sensitivity and specificity of 100%. Kinsella et al.[14] observed a good correlation between capillary BHOB and blood glucose (P = 0.02). Similar observations were made by Naunheim et al. showing good correlation between capillary BHOB and blood glucose (P< 0.001)[12] Klocker et al.,[15] Misra and Oliver,[16] Bryne et al.,[17] and Federici and Benedetti[18] in their studies observed a good correlation between capillary BHOB levels and clinical recovery and traditional markers of acidosis: PH, bicarbonate, and fatty acids.

Capillary BHOB method offers many advantages such as point-of-care testing, rapid result, cost-effective, excellent clinical correlation, and correlation with markers of ketoacidosis. It can be done in oliguric or anuric patients where getting a urine sample is delayed and difficult. As it measures the predominant ketone in the blood, it prevents unnecessarily prolonged insulin administration based on urine dipstick method. Although Shahzad et al.[11]et al. did not find overall correlation between capillary BHOB and traditional acidosis markers, there was a clinical correlation between the trend of capillary BHOB and course of DKA. The lack of relationship may be due to acidosis contributed by acute kidney injury (AKI) (they had a high number of patients with AKI), lactic acidosis, and hyperchloremia. Another limitation of the study was that it is a retrospective study with a small sample size. However, this point-of-care, easy-to-perform, rapid, and low-cost biochemical assay can help clinicians to diagnose, monitor, and treat DKA at the bedside and this option needs to be explored and further studied in a larger group of patients.



 
  References Top

1.
Savage MW, Dhatariya KK, Kilvert A, Rayman G, Rees JE, Courtney CH, et al. Joint British diabetes societies guideline for the management of diabetic ketoacidosis. Diabet Med 2011;28:508-15.  Back to cited text no. 1
    
2.
Tentolouris N, Katsilambros N. Diabetic ketoacidosis in adults. In: Diabetic Emergencies Diagnosis and Clinical Management. Katsilambros N, Kanaka-Gantenbein C, Liatis S, Makrilakis K, Tentolouris N, editors. 1st ed. Hoboken, NJ, USA: John Wiley and Sons; 2011.  Back to cited text no. 2
    
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Dunning T. Care of people with diabetes: A manual of nursing practice. 4th ed.. West Sussex, UK: Wiley Blackwell; 2014.  Back to cited text no. 3
    
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Noyes KJ, Crofton P, Bath LE, Holmes A, Stark L, Oxley CD, et al. OHB near-patient testing to evaluate a new end-point for intravenous insulin therapy in the treatment of diabetic ketoacidosis in children. Pediatr Diabetes 2007;8:150-6.  Back to cited text no. 5
    
6.
Tantiwong P, Puavilai G, Ongphiphadhanakul B, Bunnag P, Ngarmukos C. Caplillary blood beta-OHB measurement by reagent strip in diagnosing diabetic ketoacidosis. Clin Lab Sci 2005;18:139-44.  Back to cited text no. 6
    
7.
Katsilambros N, Kanaka-Gantenbein C, Liatis S, Makrilakis K, Tentolouris N. Diabetic emergencies diagnosis and clinical management. 1st ed. Hoboken, NJ, USA: John Wiley and Sons; 2011.  Back to cited text no. 7
    
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Diabetes UK. Diabetes in the UK 2011–2012 Key Statistics on Diabetes. Available online: Available from: http://www.diabetes.org.uk/About_us/What-we-say/Statistics/Diabetes-in-the-UK-2012/Last (13). [Last accessed on 2020 Jun 15].  Back to cited text no. 8
    
9.
Voulgari C, Tentolouris N. The performance of a glucose-ketone meter in the diagnosis of diabetic ketoacidosis in patients with type 2 diabetes in Emergency Room. Diabetes Technol Ther 2010;12:529-34.  Back to cited text no. 9
    
10.
Arora S, Henderson SO, Long T, Menchine M. Diagnostic accuracy of point-of-care testing for diabetic ketoacidosis at emergency-department triage. Diabetes Care 2011;34:852-4.  Back to cited text no. 10
    
11.
Shahzad M, Haque A, Mirza S, Jurair H, Ahmed RA, Khalid M. Role of capillary blood ketone assay in diagnosis and management of diabetic ketoacidosis in pediatric intensive care unit. J Pediatr Crit Care 2020;7:316-20.  Back to cited text no. 11
  [Full text]  
12.
Naunheim R, Jang TJ, Banet G, Richmond A, McGill J. Point-of-care test identifies diabetic ketoacidosis at triage. Acad Emerg Med 2006;13:683-5.  Back to cited text no. 12
    
13.
Charles RA, Bee YA, Eng PH, Goh SY. Point-of-care blood ketone testing: Screening for diabetic ketoacidosis at the emergency department. Singap Med J 2007;48:986.  Back to cited text no. 13
    
14.
Kinsella JM, Barker G, King J, Webber MG, Boyd M, Ho KW, et al. Implementing point of care blood ketone testing in the emergency department. Aust Emerg Nurs J 2012;15:63-7.  Back to cited text no. 14
    
15.
Klocker AA, Phelan H, Twigg SM, Craig ME. Blood β-hydroxybutyrate vs. urine acetoacetate testing for the prevention and management of ketoacidosis in Type 1 diabetes: A systematic review. Diabet Med 2013;30:818-24.  Back to cited text no. 15
    
16.
Misra S, Oliver NS. Utility of ketone measurement in the prevention, diagnosis and management of diabetic ketoacidosis. Diabet Med 2014;32:14-23.  Back to cited text no. 16
    
17.
Bryne HA, Tieszen KL, Hollis S, Dornan TL, New JP. Evaluation of an electrochemical sensor for measuring blood ketones. Diabetes Care 2000;23:500-3.  Back to cited text no. 17
    
18.
Federici MO, Benedetti MM. Ketone bodies monitoring. Diabetes Res Clin Pract 2006;74:S77-81.  Back to cited text no. 18
    




 

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