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Hospital Admissions (2) to Non Keto Centre

The following information has been kindly supplied to us by Dr. Ruth Williams, Paediatric Neurologist from Evelina Hospital (Guys & St. Thomas’s Trust) & MF Medical Board.  This is based on the information that her and her team have drawn up for their patients.

CHILDREN ALREADY ESTABLISHED ON THE KETOGENIC DIET PRESENTING WITH INTERCURRENT ILLNESS OR FOR ELECTIVE PROCEDURES ETC.

1. As soon as possible after admission, contact medical and KD team/ward dietician.

2. Test urine for ketones every time child passes urine

3. Daily weights

4. BMStix 4 hourly for sick child or if NBM, or twice daily otherwise.
(note that if the child is ketotic, BM may be low but still acceptable, ie. 1.5-3.0mmol)

5. Avoid sugar and carbohydrate containing drugs and IV solutions.  If you are unsure of the sucrose, lactose, glycerol or corn/maize content, you should contact the pharmaceutical company directly.  Numbers are listed in the Paediatric BNF. If in doubt, substances ending in “ose” or “ol” are usually converted to glucose in the body.

6. Urgent bloods if child is sick:
      FBC, Renal function, bicarb, liver function, lactate
      Urinalysis
      Blood gas
     
7. Emergency management of symptomatic hypoglycaemia or BMStix <1.5mmol
 Please check blood sample lab sugar and give emergency drink.

      Younger than 5 years old:
5g (1 level teaspoon) maxijul powder in 50mls water or low-carbohydrate squash

      Older than 5 years old:
10g (2 level teaspoon) maxijul powder in 100mls water or low-carbohydrate squash

8. Rehydrate with clear fluids if tolerated orally – water, sugar-free squash.  As soon as possible, return back onto ketogenic diet.

Management guidelines for children on Ketogenic Diet undergoing General Anaesthetic

The literature on ketogenic diet and GA is scarce, with very little consensus on management.

The most comprehensive study undertaken so far suggests that carbohydrate-free solutions are safe and blood glucose remains stable throughout surgical procedures up to 1.5 hours. The most common effect noted in procedures > 3 hours was a significant decrease inpH, requiring IV bicarbonate. Current advice suggest therefore monitoring blood pH in procedures > 3 hours and administering IV Bicarbonate where necessary.
(Valencia et al, 2002; Epilepsia; vol 43, issue 5; p525)

1. Contact KD team for relevant speciality

2. Check all urine for ketones on dipstick

3. Take bloods:
      FBC
      Renal function
      Bicarbonate
      Liver function
      Urinalysis
      Blood Gas
      Glucose
      Lactate
     
4. Keep NBM for normal recommended time period (6 hours food / milk – Clear fluids 2 hours)

5. Insert IV Cannula

6. Give normal saline at appropriate rate

7. Continue with carbohydrate-free solution throughout anaesthetic (use either 0.9% NaCl or Ringers lactate)

8. If anaesthetic is > 3 hours monitor blood gas (pH and bicarbonate) and consider IV bicarbonate if increase in acidosis

9. Continue IV normal saline until oral fluids tolerated

10. Re-introduce normal (ketogenic) diet as soon as possible.