title: Urinary acetoacetate or capillary beta-hydroxybutyrate for the diagnosis of ketoacidosis in the Emergency Department setting.
abstract: OBJECTIVE
  We compared the semiquantitative measurement of acetoacetate using urinary dipsticks with the bedside quantitative fingerprick measurement of the principal ketone bodies 3-beta-hydroxybutyrate, for the diagnosis of ketoacidosis.
  
  
  METHODS
  This is a one year retrospective study of patients who presented with hyperglycemia levels of 250 mg/l or greater in the Emergency Department setting. We compared the sensitivity, specificity, and predictive value of ketonuria and ketonemia for the diagnosis of ketoacidosis (urine or blood ketone bodies, blood bicarbonates <20 mmol/l, anion gap >16 meq/l) in a sample of patients for whom the levels of ketone bodies in the blood and urine as well as serum electrolytes were available.
  
  
  RESULTS
  We studied 355 hyperglycemic patients. The median time between arrival and dipstick testing was 21 min, and was greater than 2 h in more than 10% of cases. Comparison between ketonuria and ketonemia was performed in 173 patients (6% with diabetic ketoacidosis). Ketonuria equal to or less than one cross or a 3-beta-hydroxybutyrate value lower than 3 mmol/l enabled ketoacidosis to be excluded (negative predictive value 100%). At two-cross cutoff points for ketonuria and at the 3 mmol/l cutoff point for ketonemia, the two tests had the same sensitivity (100%), but the specificity of 3-beta-hydroxybutyrate (94%) was significantly higher (P<0.0001) than that of ketonuria (77%). The best positive predictive value for ketonemia was obtained at the 5 mmol/l cutoff point (100%) and for ketonuria at the three-cross cutoff point (26%). At the three-cross cutoff point for ketonuria and at the 5 mmol/l cutoff point for ketonemia, the two tests had the same negative likelihood ratio (0.1), but the positive likelihood ratio of 3-beta-hydroxybutyrate (infinite) was higher than that of ketonuria.
  
  
  CONCLUSIONS
  The measurement of 3-beta-hydroxybutyrate in capillary blood is faster and more effective than the use of dipsticks in the urine to detect ketoacidosis in the Emergency Department setting.
authors.affiliation: Department of Emergency Medicine, Hopital Saint-Louis, University of Paris VII, Paris, France. pierre.taboulet@sls.ap-hop-paris.fr
authors.forename: Pierre
authors.initials: P
authors.lastname: Taboulet
authors.forename: Laurent
authors.initials: L
authors.lastname: Haas
authors.forename: Raphael
authors.initials: R
authors.lastname: Porcher
authors.forename: Jaffar
authors.initials: J
authors.lastname: Manamani
authors.forename: Jean-Paul
authors.initials: JP
authors.lastname: Fontaine
authors.forename: Jean-Paul
authors.initials: JP
authors.lastname: Feugeas
authors.forename: Jean-Francois
authors.initials: JF
authors.lastname: Gautier
mesh_terms: D020155:3-Hydroxybutyric Acid / Q000032:analysis / Q000652:urine*; D000090:Acetoacetates / Q000032:analysis / Q000652:urine*; D015415:Biomarkers / Q000032:analysis; D002196:Capillaries / Q000737:chemistry; D016638:Critical Illness; D016883:Diabetic Ketoacidosis / Q000175:diagnosis / Q000652:urine*; D004636:Emergency Service, Hospital; D004638:Emergency Treatment / Q000379:methods; D005260:Female; D006801:Humans; D007657:Ketone Bodies / Q000652:urine; D008297:Male; D011237:Predictive Value of Tests; D011379:Prognosis; D012189:Retrospective Studies; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D016482:Urinalysis / Q000379:methods*
chemical_list: D000090:Acetoacetates; D015415:Biomarkers; D007657:Ketone Bodies; C016635:acetoacetic acid; D020155:3-Hydroxybutyric Acid