Hydroxybutyrate near-patient testing to evaluate a new end-point for intravenous insulin therapy in the treatment of diabetic ketoacidosis in children
Open accessAbstract
BACKGROUND: The aim of this study was to assess the clinical application of a near-patient testing (NPT) device for capillary blood hydroxybutyrate (HOB) measurement in evaluating a new end-point for intravenous insulin therapy in the treatment of diabetic ketoacidosis (DKA) in children. METHODS: Children fulfilling the criteria for DKA were treated according to an integrated care pathway (ICP) with fluid replacement and insulin infusion. We measured capillary HOB hourly by NPT (Abbott Optium meter, analytical range 0-6.0 mmol/L), venous blood gases 4 hourly, and venous HOB 4 hourly by laboratory enzymatic method and tested all urine passed for ketones. Two possible ICP end-points were compared: A, pH > 7.3 followed by two successive NPT HOB measurements <1 mmol/L, and B, pH > 7.3 and urine ketone free (our current end-point). RESULTS: In 35 patient episodes, the ICP was completed (28 to negative ketonuria) without significant variation. Before treatment, median (range) laboratory HOB was 9.5 mmol/L (4.6-15.70 mmol/L), pH 7.18 (6.98-7.38), and standard bicarbonate 11.5 mmol/L (4.3-18.6 mmol/L). ICP end-point A was reached after 17 h (4-39 h), whereas end-point B was not reached until 28 h (14-64 h) after starting treatment. The median lag was 11 h (1-36 h). For 59 paired venous samples (excluding samples with laboratory HOB >6 mmol/L), the relation between NPT (y) and laboratory (x) HOB was y = 0.92x - 0.05, r(2)= 0.94, mean bias -0.25 mmol/L. CONCLUSIONS: (i) Serial measurement of NPT HOB allows evaluation of a new, simple, earlier end-point for intravenous insulin therapy. (ii) Agreement between NPT and laboratory HOB was clinically acceptable for HOB levels within the meter's analytical range.
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In that study, the comparator was conversion when urine ketones were negative, which is not a typical marker for resolution.
“However, the comparator was conversion when urine ketones were negative, which is not a typical marker for resolution (308).”
From Guidelines and Recommendations for Laboratory Analysis in the Diagnosis and Management of Diabetes Mellitus (2023) · cites this paper as [308]
The Abstract identifies the comparator as the study’s current end-point B, but it required both pH above 7.3 and ketone-free urine—not negative urine ketones alone. The Discussion supports the qualification that negative urine ketones are not a generally required marker for transition: it says guidelines allow urinary ketones to remain present and that practice varies between centres. (LLM, conf=0.86)
Experimental — accuracy not yet measuredOne small study in children with diabetic ketoacidosis found that use of a point-of-care assay for beta-hydroxybutyrate decreased time to conversion from intravenous to subcutaneous insulin.
“One small study in children with DKA found that use of a POC assay for bOHB decreased time to conversion from intravenous to subcutaneous insulin.”
From Guidelines and Recommendations for Laboratory Analysis in the Diagnosis and Management of Diabetes Mellitus (2023) · cites this paper as [308]
In 'During treatment' (page not available), the proposed point-of-care hydroxybutyrate end-point was reached a median of 11 hours before the urine-ketone end-point in 28 pediatric DKA episodes. But the study states that hydroxybutyrate results did not inform clinical decisions; it therefore shows a potential for earlier conversion, not that using the assay actually decreased time to conversion. (LLM, conf=0.88)
Experimental — accuracy not yet measuredBlood ketone measurements that specifically measure beta-hydroxybutyrate are useful for both diagnosis and ongoing monitoring of diabetic ketoacidosis.
“Blood ketone measurements that measure bHBA specifically are useful for both the diagnosis and ongoing monitoring of DKA (194)(195)(196).”
From Guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus (2011) · cites this paper as [196]
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Cites
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- Authors
- Noyes, K. J., Crofton, P., Bath, L. E., Holmes, A., Stark, L., Oxley, C. D., & Kelnar, C. J. H.
- Affiliations
- Royal Hospital for Sick Children (GB)
- Corresponding author
- Noyes, Kathryn J
- Venue
- Pediatric Diabetes
- Publisher
- Hindawi Limited
- Published
- 2007-06
- Volume
- 8
- Issue
- 3
- Pages
- 150-156
- ISSN
- 1399-543X (ISSN-L)
- 1399-5448
- OpenAlex
- W2031696902
- Semantic Scholar
- 7d2932733bfbd4fe30f8a92733bdbe5f0de8a3a7
- Cited by
- 65
- References
- 10
- Citations by year
- 2025: 1 · 2024: 2 · 2023: 5 · 2022: 6 · 2021: 8 · 2020: 2 · 2018: 2 · 2017: 3 · 2016: 5 · 2015: 1 · 2014: 9 · 2013: 2 · 2012: 3
- FWCI
- 3.17
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Pediatric Diabetes (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Abbott Diabetes Care
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
- Health Sciences › Medicine › Physiology › Clinical Laboratory Practices and Quality Control
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Hyperglycemia and glycemic control in critically ill and hospitalized patients
- Keywords
- hydroxybutyrate, point-of-care testing, diabetic ketoacidosis, children, intravenous insulin therapy, capillary blood, integrated care pathways, ketonuria, blood pH, venous blood gas, point-of-care monitoring
- MeSH terms
- Adolescent, Child, Child, Preschool, Environmental Monitoring, Female, Humans, Hydrogen-Ion Concentration, Hypoglycemic Agents, Infant, Infusions, Intravenous, Insulin, Ketone Bodies, Male, Biomarkers, Diabetic Ketoacidosis, 3-Hydroxybutyric Acid
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