Ketogenic Diet Guide for General Critical Care

AIM: Ketogenic diet (enteral feed) for the management of refractory epilepsy and other neurological conditions

A ketogenic diet is a high fat, low carbohydrate, adequate protein diet which requires careful monitoring of blood glucose and ketones as the very low carbohydrate intake triggers an adaptive response; upregulating fatty acid oxidation in the liver and leading to the circulation of ketones in the blood. It effectively mimics the metabolic effects of fasting. Fat replaces carbohydrate as the body’s primary fuel. For the most recent feeding regimen please see the clipboard/nursing notes.

1. Products – The following products will be provided to the unit by the dietitian/pharmacist. If stocks are running low, please inform the dietitian before you run out.

- Ketocal 4:1 LQ Multifibre or Ketocal 2.5:1 (see regimen). It should be stored in the fridge once opened and used within 24 hours of opening. - Prosource TF. Once open use immediately and discard any waste. - Maxijul. Once opened, use within 1 month. - 500mls flexible containers and giving sets (new container and giving set every 5 hours). Note: Not provided by dietitian/pharmacist.

2. Ketogenic monitoring parameters

Monitor blood glucose and ketones 4 hourly (or more frequently if clinical concerns)

Target range for Ketones is 2-5mmol/l and Blood Glucose 3-5mmol/l

Blood ketones (in nutritional ketosis) Blood glucose (in nutritional ketosis)

• Normal level is 1-5 mmol/L (beta- • Normally at the lower end of the normal range; hydroxybutyrate) • 3-5mmol/l but should be HIGHER than 2.5 mmol/L • Levels higher than 5 mmol/L may lead to symptoms of hyperketosis: lethargy, • Levels of 2.5 mmol/L or below may lead to symptoms fatigue, irritability, facial flushing, of hypoglycaemia: lethargy, fatigue, irritability, vomiting and panting. dizziness, sweating, pallor, confused, cold/clammy

²Date: 03/06/2019 ²Revision Due: 03/06/2022

This guideline has been developed for the benefit of those working in Critical Care at The James Cook University Hospital. While every effort has been made to check the accuracy of the contents, the use of this guideline is subject to professional judgement and no responsibility or liability will be accepted for any cost or damage arising from its use. 2019 © South Tees Hospitals NHS FT

What to do if blood ketone level is HIGHER than 5 mmol/L or blood glucose is LOWER than 3 mmol/L:

• Please give one dose of 5 g glucose (e.g. 20 mL Glucojuice) via NGT with 30 mL water flush pre and post

• Recheck blood levels after 20 minutes and repeat treatment as necessary

Please refer to South Tees intranet for treatment of hypoglycaemia in adults (2016). If concerns be aware it will likely affect ketosis and may exacerbate seizure activity

• If ketones are <2 mmol/L you do not need to do anything- this will be picked up on dietetic review and the feeding regimen may be altered.

• Avoid carbohydrate containing medications/IVT if possible (e.g. mix meds with IV saline rather than dextrose)

• Monitor bowels – patients following ketogenic diet may be prone to constipation (may require laxido/movicol)

• Ensure adequate hydration as ketogenic diet may slightly increase diuresis. Ensure adequate NGT water flushes (caution with diuretics).

• Monitor bicarbonate levels as per critical care. Ketogenic diet may increase risk of acidosis in the initiation phase.

• Monitor weight once weekly.

• See biochemistry monitoring sheet for further information regarding blood tests and frequency.

PROPOFOL MUST NOT BE USED AS THERE IS A SIGNIFICANT RISK OF PROPOFOL INFUSION SYNDROME IF USED DURING KETOSIS

²Date: 03/06/2019 ²Revision Due: 03/06/2022

Authors: Siobhan Stewart/ Rachel Edson. Adapted from NHS Nottingham Foundation Trust Quick Guide to Ketogenic Diet – Hayley Ryan (Dietitian) and Enteral Ketogenic Diet Therapy: feed provision for adults (Susan Wood- Ketogenic Dietitian 2019) ² ² Date: 03/06/2019 Revision Due: 03/06/2022 This guideline has been developed for the benefit of those working in Critical Care at The James Cook University Hospital. While every effort has been made to check the accuracy of the contents, the use of this guideline is subject to professional judgement and no responsibility or liability will be accepted for any cost or damage arising from its use. 2019 © South Tees Hospitals NHS FT