If a patient on the Ketogenic Diet presents to your Emergency Department due to illness, the Ketogenic Diet should take second place to the treatment necessary for the presenting complaint. However, wherever possible, sugar-free medications (or those with minimal carbohydrate content) should be used and the treating team should aim to maintain ketosis to avoid seizure activity, and avoid hypoglycaemia.
Refer to the patient’s Emergency Letter (if available) and consider the following recommendations specific to Ketogenic Diet patients:
- Resuscitate as per usual protocols
- Administer normal saline bolus (as per child’s age and requirements)
Investigations specific to being on the diet:
- Unwell KD patients require close and regular monitoring
- Avoid hypoglycaemia, particularly if vomiting or diarrhoea present (at least 4-hourly bedside checks of blood glucose required) (Refer to: Management of Hypoglycaemia on the Ketogenic Diet flowchart for more detailed information).
- Avoid high ketone levels (at least 4-hourly urine samples to check ketone levels). If the urine ketone levels are high, perform blood ketones (beta-hydroxybutyrate). Avoid blood ketone level of > 7 mmol/L.
- Venous gas (to check for metabolic and lactic acidosis)
- Electrolytes (look for hypernatraemia, hyper/hypo-kalaemia)
- Lactate (looking for elevated lactate)
- Where hydration is required, aim to use fluids containing the lowest possible dextrose level, while maintaining blood sugar levels in the normal range.
- Oral hydration: offer clear fluids low in carbohydrate (e.g. hydrolyte, gastrolyte, diet cordial).
- IV hydration: Normal saline as IV fluid in most cases but if there are concerns re: hypoglycaemia or prolonged IV use, consider adding low dextrose fluids to IV (e.g. 2.5% dextrose) in conjunction with the Normal Saline.
- NG hydration: consider using gastrolyte as this contains no more than 3% glucose
- Regular ongoing monitoring of glucose (as per the Hypoglycaemia Protocol) and ketones is required and medical staff should chart dextrose, glucagon or polyjoule as necessary (see hypoglycaemia protocol for dosages).
- It is essential that any newly prescribed medications are sugar-free (or contain minimal carbohydrate content). This applies to all medication including cough syrups, pain relief and antibiotics (e.g. syrups may need to be changed to sugar-free liquids or to crushable tablets). Compounding can be discussed with the patient’s local Pharmacy.
- Consider placing an alert to avoid sugar and carbohydrates in the Allergies section of the medication chart for patients on the ketogenic diet.
If additional advice or support is required, contact the patient’s treating Ketogenic team or the relevant Neurology Fellow on-call directly.