UPDARD GUIDELINES FOR MANAGEMENT OF DIABETIC KETOACIDOS

[nizarsedon]

[ ]Definition
Severe uncontrolled known diabetes or new presentation
Blood Glucose > 11mmol/l
Bicarbonate (HCO3) < 15 mmol/l and /or venous PH < 7.3
The Presence of one or more of the following may indicate severe DKA
and require admission to the critical care unit
Pregnancy, Bicarbonate < 5 mmol/l, Venous pH < 7.1, Hypokalaemia on admission <3.5 mmol/l
GCS < 12, Oxygen saturation < 92 %, Systolic BP below 90 mmHg, Pulse < 60 or > 100 bpm
Anion Gap > 16
Step 1: 0 - 60 MIN
IMMEDIATE MANAGEMENT
FLUID REPLACEMENT
- IV Cannula
- Start 0.9% Sodium Chloride 1000ml/hour
(All fluids / potassium and insulin must be
prescribed on the main prescription chart)
INITIAL INVESTIGATIONS
- U&Es, HCO3 and Anion gap
- Plasma Blood Glucose
- Venous pH
- Fluid balance
- Urine ketones
START INSULIN
- Soluble 6 units/hour IV
- Continue Long Acting Analogue Insulin
i.e. Lantus / Levemir
OTHER INTERVENTIONS
- Document Glasgow Coma Scale
- Consider central line
- Consider cardiac monitoring
- Nasogastric tube if vomiting or airway
unprotected
- Discontinue insulin pump if insulin pump
patient
- Inform Diabetes Specialist Nurse
Mon – Fri bleep 2205 / #3104
- Inform Endocrine F1 Mon – Fri
9am – 5 pm
- Inform Endocrine ward and site team
Tick boxes when
task completed
SUPPLEMENTARY NOTES
Typical Fluid replacement regimen
Fluid Volume
0.9% Sodium chloride 1L 1000ml over 1 hr
0.9% Sodium chloride 1L with KCL 1000 ml over next 2 hrs
0.9% Sodium chloride 1L with KCL 1000 ml over next 2 hrs
0.9% Sodium chloride 1L with KCL 1000 ml over next 4 hrs
0.9% Sodium chloride 1L with KCL 1000 ml over next 4 hrs
0.9% Sodium chloride 1L with KCL 1000 ml over next 6 hrs
START INSULIN
Use soluble insulin e.g. Actrapid or Humulin S
- Concentration should be 50 units of insulin made up to
50mls of normal saline administered through a syringe
pump.
- Insulin should be prescribed on the regular section of the
main prescription chart.
- Fluids, insulin and potassium must be prescribed on the
main prescription chart
- Insulin may be infused in the same line as the intravenous
replacement fluid provided that a Y connector with a one way
anti-syphon valve is used and a large-bore cannula has been
placed
MEWS
Record MEWS as per hospital policy and report mews score of
moderate or high to Doctor / Senior nurse for review, and
maintain observations as per MEWS risk assessment
POTASSIUM
Potassium Replacement – 40mmols/KCL must be in 1 litre of
fluid. Under no circumstances should KCl be administered at a
rate greater than 20 mmol/hour unless facilities for intensive
monitoring are available
INFORM STAFF
Will require an Endocrine bed in 8 – 10 hours
Page 3 of 9
Step 2: Hours 60 mins – 6 hours
ON GOING MANAGEMENT
BIOCHEMICAL and CLINICAL MONITORING
60 mins Hour 2 Hour 4 Hour 6
- U&Es / Anion gap / bicarb
- Venous pH
- Document GCS
- Hourly Blood Glucose

FLUID and ELECTROLYTES
- Continue with 0.9% Sodium Chloride
according to patient’s volume requirements
- Use potassium containing fluids unless anuric
40mmols/L if serum K+ < 3.5 – 5 mmol/l
INSULIN and DEXTROSE
- Infuse insulin at 6 units/hr if blood glucose is falling at
less than 5 mmol/L/hr,
- Reduce insulin infusion to 3 units/hr if blood glucose is
falling at more than 5 mmol/L/hr

Insulin rate checked
- Infuse 10% dextrose at 100ml/hour if blood glucose <14
mmol/L at 125 ml/hr along side 0.9% sodium chloride
- Continue Long Acting Analogue Insulin
i.e. Lantus / Levemir
(All fluids / potassium and insulin must be prescribed on
the main prescription chart)
OTHER INVESTIGATIONS AS INDICATED
- Chest X Ray
- ECG
- MSU
- Blood cultures
- Viral titres
- Full blood count
- Urinary catheter if diuresis has not occurred
Tick boxes when
task completed
SUPPLEMENTARY NOTES
BIOCHEMICAL AND CLINCIAL MONITORING
Blood Glucose Monitoring / Recording
Measure capillary blood glucose hourly
If meter reads “blood glucose > 20 mmol/L or HI” venous
blood should be sent to the laboratory hourly or measured in
a blood glucose analyser until the bedside meter is within its
QA range
Record blood glucose on the CHA 2306 Diabetic Monitoring
and Sliding Scale chart. Ensure that the sliding scale insulin
prescription is crossed through and not used
BICARBONATE
If the bicarbonate is not rising by at least 3 mmol/L gain
senior medical review
FLUID and ELECTROLYTES
Potassium Replacement – 40mmols/KCL must be in 1 litre
of fluid. Under no circumstances should KCl be
administered at a rate greater than 20 mmol/hour unless
facilities for intensive monitoring are available
INSULIN and DEXTROSE
Blood glucose can return to normal before ketones are
removed from the blood.
Continue with intravenous insulin at 3 or 6 units until pH >
7.3 and bicarbonate > 12 mmol/L, unless patient
deteriorates
Ensure that long acting insulin has been continued
and prescribed on the main prescription chart
Insulin may be infused in the same line as the intravenous
replacement fluid provided that a Y connector with a one
way anti-syphon valve is used and a large-bore cannula has
been placed
MEWS
Record MEWS as per hospital policy and report mews score
of moderate or high to Doctor / Senior nurse for review, and
maintain observations as per MEWS risk assessment
CEREBRAL OEDEMA
Children (refer to paediatric guideline) and adolescents are
at the highest risk, which may be increased if blood glucose
falls at rates of > 5mmolL per hour.
Presentation is with headache or declining GCS in a patient
who is otherwise biochemically improving. If cerebral
oedema is suspected refer to critical care

Step 3: Hour 6
ON GOING MANAGEMENT
BIOCHEMICAL and CLINICAL
MONITORING
- Review U&Es / Anion gap / bicarb
- Review Venous pH
- Document GCS
If DKA resolved , pH > 7.3,
bicarbonate > 12 mmolL
go to Step 4
If DKA not resolved return to Step 2
and
seek senior specialist advise as a matter of
urgency
SUPPLEMENTARY NOTES
ON GOING MANAGEMENT
The aim is to:
- ensure that clinical and biochemical
parameters are improving
- continue IV fluid replacement
- continue insulin administration
- assess for complications of treatment
- continue to treat precipitating factors
- avoid hypoglycaemia
DSN
DSN to inform Endocrine team if patient
requires prolonged stay in Level 2 care
setting
]Step 4: Hours 6 – 24
- after 8 hours if no signs of sepsis or other
remaining medical precipitant of DKA pt
can move out of a level 2 care setting
- If the patient is not eating and drinking
and there is no ketonuria change to a variable
rate insulin infusion (standard sliding scale
insulin infusion)
- If the patient is eating and drinking convert
back to an appropriate subcutaneous insulin
regimen.
Ensure that the long acting insulin has been
continued and administered prior to
discontinuing the intravenous insulin infusion
at a meal time.
(if not see below)
Recommence long acting insulin if not
continued as per steps 1 / 2 at least 6 hours
prior to discontinuing the intravenous insulin
infusion at a meal time

- Transfer to endocrine ward
Tick boxes when
task completed
DISCHARGE PLAN
SPECIALIST REVIEW
To determine cause of episode and review
diabetes education
Refer as indicated to
- Diabetes Specialist Nurse
- Endocrinologist
DISCHARGE ONLY WHEN
- Biochemically stable
- Eating and drinking
- Established on subcutaneous insulin regimen
FOLLOW UP
- Diabetes Specialist Nurse
- Outpatient Endocrinologist appointment
arranged
- Copy of the discharge letter to the diabetes

[moyassar]

Thanks for the great effort and valuable topic....