Urine Ketone Dip Test as a Screen for Ketonemia in Diabetic Ketoacidosis and Ketosis in the Emergency Department,☆☆,,★★

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Abstract

Study objective: To determine the sensitivity of the urine ketone dip test (UKDT) for the detection of ketonemia in patients with diabetic ketoacidosis (DKA) and diabetic ketosis (DK) in the ED. Methods: We conducted a retrospective chart review in the ED of an urban, university- affiliated county teaching hospital. The study population comprised patients seen in the ED during 1994 and 1995 with a discharge diagnosis of DKA or DK and underwent urinalysis within 4 hours of the initial serum electrolyte and ketone determinations. We calculated test sensitivity, along with 95% confidence intervals (CIs). Results: One hundred forty-eight patients with 223 occurrences diagnosed as DKA or DK were seen in the ED during the study period. One hundred fourteen patients with 146 occurrences of DKA or DK met all inclusion criteria; these patients made up the study group. There were 99 cases of DKA and 47 cases of DK. The sensitivity of the UKDT for the detection of ketonemia in all patients with DKA or DK was 97% (95% CI, 94% to 99%) . In the subgroup of patients with DKA, the sensitivity of the UK was 97% (95% CI, 92% to 99%). For patients with DK, the sensitivity of the UK was 98% (95% CI, 89% to 99%). Conclusion: The UKDT is highly sensitive for the presence of serum ketones in patients with DKA and DK. Prospective study is suggested to determine the specificity of the UKDT in this application and to validate its use as a screening tool for the detection of ketonemia in DKA and DK. [Hendey GW, Schwab T, Soliz T: Urine ketone dip test as a screen for ketonemia in diabetic ketoacidosis and ketosis in the emergency department. Ann Emerg Med June 1997; 29:735-738.]

Section snippets

INTRODUCTION

Early detection and treatment of diabetic ketoacidosis (DKA) and diabetic ketosis (DK) is important in reducing the morbidity and mortality of diabetes.1, 2 Patients with diabetes often present to the ED with nonspecific symptoms that may represent early DKA.1, 2 An effective screening test for DKA and DK could help clinicians decide quickly which patients with nonspecific symptoms require further serum analysis. Many clinicians use the urine ketone dip test (UKDT) as a screening test for DKA

MATERIALS AND METHODS

This study was conducted in the ED of an urban Level I trauma center with 60,000 annual patient visits. We retrospectively reviewed the charts of all cases of DKA or DK in the ED between January 1, 1994, and December 31, 1995. The patient list was generated with the Medical Records computer system, using ICD-9 codes 250.10 through 250.13. Each chart was reviewed by one of the authors with the use of a standardized data-abstraction form. From each chart we recorded demographic data, insulin

RESULTS

During the 2-year study period, 148 patients presented with 223 occurrences of DKA or DK. Three cases were eliminated from the study population because the charts were not available for review. Twenty-two were eliminated because they actually involved isolated hyperglycemia or other complications of diabetes rather than DKA or DK. Six were eliminated because serum ketone test results were negative. In three cases, patients were transferred or readmitted to our hospital partially treated and

DISCUSSION

The UKDT is considered useful in the diagnosis of DKA.1, 2, 3, 4, 5, 6 Other investigators have studied urinalysis in the diabetic patient, although none has examined the role of the UK as a screening test for DKA and DK in the ED.

The main ketone bodies excreted in human beings are β-hydroxybutyrate, acetoacetate, and acetone. Standard tests for urine and serum ketones (eg, Acetest) depend on the nitroprusside reaction, which reflects only the presence of acetoacetate and acetone.

Acknowledgements

We thank Kay Bertken, PhD, for her assistance and expertise in statistical analysis.

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    However, the relative contributions of AcAc, 3HB, and Ac cannot be quantified from bedside assays or the usual laboratory analysis of ketones.8,9 The gold standard for detection of ketones, the urine ketone dip-stick test (Ketostix; Bayer, Pittsburgh, PA; Ames, Elkhart, IN), has several limitations because this technique uses the Legal nitroprusside reaction, which only detects AcAc and Ac, but not 3HB.10 Moreover, the Legal assay is affected by air and substances such as captopril (Capoten), N-acetylcysteine (Mucomyst), dimercaparol (British antilewisite), as well as penicillamine (Cuprimine), which may interfere with the results.11

  • Point of care testing in the emergency department

    2002, Journal of Emergency Medicine
  • Screening for ketonemia in patients with diabetes

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From the Department of Emergency Medicine, University Medical Center, Fresno, CA.

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Funded by a Grant from the Valley Medical Center Foundation.

Reprint no.47/1/81765

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Address for reprints: Gregory W Hendey, MD University Medical Center Emergency Medicine 445 South Cedar Avenue Fresno, CA 93702

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