Insulin Pump - Ketone Management

These instructions are protocols for ketone management for Children's Hospital of Philadelphia (CHOP) patients who use an insulin pump to manage their diabetes.

Patient instructions:

• Ketones are acids that form in the body from a lack of insulin.

• The body may develop ketones when the pump is not delivering insulin.

  • This could be because the cannula, tube under the skin, is bent, kinked, or dislodged. There could also be an issue with the cartridge holding the insulin.

• The body may develop ketones when sick with a cold.

• The blood sugar could be high or low with ketones. You and your team need to adjust the insulin to keep blood sugar in range while sick.

Follow the instructions below for insulin doses and fluid instructions:

Blood sugar over 240

Positive ketones

Basal insulin

• Change pump site and cartridge or pod.

• Once the pump site is working, maintain basal. If blood sugar is over target range for next 24 hours, use a temporary basal rate: Increase basal rate by 10% for a duration of 4 hours.

Correction bolus

• Give the first correction with an injection.

• Re-check blood sugar in 2 hours and if the blood sugar is over 240, give another correction with an injection.

• Re-check blood sugar again in 2 hours and if the blood sugar is still over 240, call the Diabetes Center for further instruction.

Food bolus

• If not vomiting, cover all carbs.

• If vomiting, call the Diabetes Center.

Extra fluids

• Sugar-free fluids

• 1 ounce per year of age every hour

Blood sugar less than 240

Positive ketones

Basal insulin

• Keep the basal rate the same.

Correction bolus

• Correct blood sugar to target every 2 hours as needed.

Food bolus

• If blood sugar is greater than 120, cover all carbs.

• If blood sugar is less than 120, do not cover carbs.

Extra fluids

• If blood sugar is low or in range, give sugary fluids to raise blood sugar in order to give a correction bolus. 1 ounce per year of age every hour

Vomiting or diarrhea
Blood sugar less than 240

Positive ketones

• Call the Diabetes Center for information on how to handle basal insulin, correction and food boluses as well as extra fluids.

Call the Diabetes Center with questions, concerns or if:

• Ketones don't clear after giving 2 ketone doses

• Your child is unable to drink

• Your child is vomiting and cannot stop

If using an automated system, please contact the diabetes center emergency numbers for assistance with ketones.

Division of Endocrinology and Diabetes

Reviewed on March 14, 2023, by Regina Taddeo, MA, RN, CDCES