LOW sugar, check ketones?

[Jedrnurse, BSN, RN]

I've had a 4 year old with T1D at school this year, and he's been very interesting. Sometimes he comes in with a blood glucose that's rollercoastering, sometimes stubbornly low, at other times it's up in the rafters.

The other day was a stubbornly low day. Lots of supplemental carbs, I even reset the pump to it's lower basal setting. I kept mom in the loop. She wondered if he was getting sick and asked me to check for ketones.

I've never heard of high ketones with a low sugar. An (admittedly) quick search for info online was a dead end. (Just articles about hyperglycemia and ketosis.)

Does anyone have any experience with this seeming paradox? If you do, any idea why it might happen?

[RatherBHiking, BSN, RN]

I had to google that too because I've also never seen that and don't have orders to check ketones unless high so it's not something I've ever done. However, I did discover that yes, illness can cause ketones even when low.

– Can you get ketones with a normal or low blood sugar?

Ketones can also be present when your blood sugar is normal or low. These are sometimes referred to as “starvation ketones” or “nutritional ketones.” During an illness or extreme diet change, if you have a significant decrease in carb intake, this can lead to the body using fat for energy because there are not enough carbs present to burn. Your blood sugar could remain normal or even be low in this case but your body could still be producing ketones.

https://beyondtype1.org/ketones/

If you have too much insulin or too little food, your body turns to fat for energy. In this case ketonuria (ketones in the urine) may be accompanied by hypoglycemia. ... In sum, your body can produce ketones when blood sugars are high or low, and is especially prone to ketonuria when you are ill.Apr 1, 1998

https://www.diabeteshealth.com/caution-dont-get-caught-with-ketones/

Interesting! I've learned something today! Thanks!

[Jedrnurse, BSN, RN]

6 minutes ago, Blue_Moon said:

I had to google that too because I've also never seen that and don't have orders to check ketones unless high so it's not something I've ever done. However, I did discover that yes, illness can cause ketones even when low.

– Can you get ketones with a normal or low blood sugar?

Ketones can also be present when your blood sugar is normal or low. These are sometimes referred to as “starvation ketones” or “nutritional ketones.” During an illness or extreme diet change, if you have a significant decrease in carb intake, this can lead to the body using fat for energy because there are not enough carbs present to burn. Your blood sugar could remain normal or even be low in this case but your body could still be producing ketones.

https://beyondtype1.org/ketones/

If you have too much insulin or too little food, your body turns to fat for energy. In this case ketonuria (ketones in the urine) may be accompanied by hypoglycemia. ... In sum, your body can produce ketones when blood sugars are high or low, and is especially prone to ketonuria when you are ill.Apr 1, 1998

https://www.diabeteshealth.com/caution-dont-get-caught-with-ketones/

Interesting! I've learned something today! Thanks!

I'll check out these links after school- thanks for the leads!

[ruby_jane, BSN, RN]

Wow. I learned a thing today. What was the result of the ketone test on your little?

[Jedrnurse, BSN, RN]

Just now, ruby_jane said:

Wow. I learned a thing today. What was the result of the ketone test on your little?

0.1, but that wouldn't necessarily mean anything. Anyway, he's back to school today, and seems healthy. Time will tell...

[ruby_jane, BSN, RN]

Mama's looking for the zebras.

Weird note- learned at camp, when the sugar won't get over 75 despite a lot of glucose tabs or juice, we added string cheese or a T of peanut butter. This was a brittle kid who was also a high metabolizer of everything. I suspect but cannot prove we provided his body an energy source other than sugar...and it worked.

[UrbanHealthRN, BSN, RN]

That was really interesting to learn about the hypo/ketone connection. I guess my only questions would be, if you have low blood sugar plus ketones, what's the clinical significance of it, and what would be the follow up? If your blood sugar is in the 400s and you have ketones, we all know what you're heading into and what next steps would be. But does having ketones with your low blood sugar really change anything? I'm super curious about this topic now!

[CanIcallmymom, BSN, RN]

In one of my high schoolers just this week, I had to check ketones when my student's blood sugar was normal, but not low. He was symptomatic but his blood sugar was fine. We checked because he was vomiting, and sure enough he had large ketones when checking his urine. His pump malfunctioned and thought it was delivering insulin somehow, but apparently was bent and not delivering. It never alarmed either.

[CanIcallmymom, BSN, RN]

Oh, and I thought I'd add. His mom picked him up, he went home and his blood sugar stayed spiked throughout the day, went up to "HIGH," then down into the 300's before he went to bed. When he woke up, it was very low but he was still urinating moderate ketones.

[tining, BSN, RN]

My student said the very same thing this week. I too said I have never checked ketones for lows. Affirmation!

[Mavnurse17, BSN, RN]

On 4/5/2019 at 8:27 AM, UrbanHealthRN said:

That was really interesting to learn about the hypo/ketone connection. I guess my only questions would be, if you have low blood sugar plus ketones, what's the clinical significance of it, and what would be the follow up? If your blood sugar is in the 400s and you have ketones, we all know what you're heading into and what next steps would be. But does having ketones with your low blood sugar really change anything? I'm super curious about this topic now!

I think this may be the basis of the Keto diet and the obsession with those dieters going into ketosis. They lower their carb intake to almost nothing (imitating low blood glucose), which forces their body to use stored fats, and the result is ketone production. I know that non-diabetics with healthy BG levels are eating this way and, as long as they're still getting adequate nutrition, it's relatively safe. There's research out there that points to damage from eating this way long-term, but I don't care to read into that since I'm not doing the diet.

In a diabetic, though, I would probably scratch my head at a request to test ketones for hypoglycemia.

[OldDude]

I think the over riding issue would be to treat the patient according to the presentation. Ketones would not be relevant in acute hypoglycemia treatment. I've never checked for ketones in a hypoglycemic patient. I'm wondering if the parent doesn't quite comprehend the ins and outs of diabetes yet.