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© 2003 by the American Diabetes Association, Inc.
Letters: Observations |
Cost Effectiveness of the Direct Measurement of 3-ß-Hydroxybutyrate in the Management of Diabetic Ketoacidosis in Children
From the Department of Pediatrics, Chair of Pediatrics, Regional Diabetes Unit, University of Parma, Parma, Italy
A system for the precise quantification of ß-hydroxybutyrate (ß-HBA) levels in capillary blood has recently been introduced in clinical practice (1). This method allows quantitative measurement of major ketone in circulation during diabetic ketoacidosis (DKA) that correlates better than acetoacetate, with changes in acid-base status during the course of treatment for DKA (2). We studied the effectiveness of this quantitative test (MediSense Optium Ketone Sensor; Abbott Laboratories, Bedford, MA) against a commercial test for urine ketone bodies (UKBs) (Keto-Diabur-Test 5,000; Roche Diagnostics, Mannheim, Germany) in monitoring DKA in order to verify whether this ketone testing method was able to reduce monitoring costs and professional burden of nurses and physicians.
A total of 33 children with severe (arterial pH 
7.2) or moderate (pH >7.27.3) DKA were studied. The treatment was the same in all patients according to a standard low-dose insulin infusion protocol. Sixteen patients were randomly monitored with blood ß-HBA (group 1) and 17 by UKB (group 2). The first advantage of the use of the ß-HBA assay concerned monitoring each patients ketotic status hourly. The goal was achieved in all of the patients of group 1, independently from their dehydration degree. Dehydration status, on the contrary, affected the regular collection of urine specimen in the patients of group 2 and prevented UKB assessment in half of them. In response to therapy, capillary blood ß-HBA levels declined 5.8 ± 0.5 h earlier than UKB levels. During the course of treatment for DKA, decreases in blood glucose and ß-HBA levels resulted parallel with one another, and decreasing concentrations of ß-HBA levels coincided with increasing concentrations of arterial pH (r = -0.82, P = 0.0001) and serum bicarbonate values (r = -0.63, P = 0.001).
Determination of ß-HBA also showed that ketosis in group 1 patients cleared (ß-HBA values <1.00 mmol/l) 4.6 ± 0.6 h sooner than patients monitored by UKB. Due to the fact that in our protocol the normalization of ketone bodies was used as end point for discharging a patient with DKA from the intensive care unit, the patients of group 1 had a shorter stay in the intensive care unit. This early discharge led in turn to a savings of 22 h for clinical assessment and 375 laboratory investigations for a total savings of (???)2,940 ($2,650), including costs for laboratory tests (29.8%) and clinical assessment (70.2%). Quantitative determination of ß-HBA levels in addition to the traditional measurement of sensitive markers of metabolic decompensation, like serum bicarbonate and anion gap, seems to offer useful information for monitoring ketosis in newly diagnosed diabetic children and for reducing time and cost in an intensive care unit.
Footnotes
Address correspondence to Pr. M. Vanelli, Department of Pediatrics, Chair of Pediatrics, Regional Diabetes Centre for Children and Adolescents, University of Parma, v.le A. Gramsci n. 14, 43100 Parma, Italy. E-mail: vanelli{at}unipr.it.
References
- Byrne HA, Dornan TL, Tieszen KL, New JP, Hollis S: Evaluation of an electrochemical sensor for measuring blood ketones. Diabetes Care 23:500–503, 2000[Abstract]
- Laffel L: Ketone bodies: a review of physiology, pathophysiology and application of monitoring to diabetes. Diabete Metab Res Rev 15:412–426, 1999
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