British society of paediatric endocrinology and diabetes bsped guidelines for the management of dka in. Determine the total daily insulin tdi requirement unitsday i. Correct ketosis and acidosis with continuous insulin. Diabetic ketoacidosis dka critical care guidelines continued transition to sq insulin guidelines for transition 1 ph 7. Weve helped produce the management of diabetic ketoacidosis in adults, pdf, 4mb published by the joint british diabetes societies inpatient car. Sc insulin should be resumed after the patient is euglycaemic, ketone free and eatingdrinking normally. Potassium chloride 80 meq iv q6h prn for serum k 4 d.
Potassium chloride 40 meq po q6h prn if k dka guideline for diagnosis hhs guideline for diagnosis. Signs and symptoms may include vomiting, abdominal pain, deep gasping breathing, increased urination, weakness, confusion and occasionally loss of consciousness. Independent of insulin therapy, hydration alone restores circulatory. Diabetic ketoacidosis dka critical care guideline two. Diabetic ketoacidosis treatment summary bnf content. Management of adult diabetic ketoacidosis aidar r gosmanov,1 elvira o gosmanova,2 erika dillardcannon3 1division of endocrinology, diabetes and metabolism, 2division of nephrology, department of medicine, 3department of microbiology, immunology, and biochemistry, university of tennessee health science center, memphis, tn, usa abstract. In adults with dka or hhs, a protocol should be followed that incorporates the following principles of treatment.
Management of diabetic ketoacidosis in adults age 16. Cbc w diff, complete metabolic panel, magnesium, phosphorus, serum osmolality, ua, abg, acetone and lactate 3. Complications occurring during dka treatment include cerebral edema and neurologic collapse. Full text management of adult diabetic ketoacidosis dmso. Acute management of diabetic ketoacidosis in adults this protocol is for the acute management of diabetic ketoacidosis in patients 16 years and over. If a patient has elevated bgl and ketones but is not acidotic they need to be closely monitored and agressively managed to prevent progression to dka. Order serum glucose and venous blood gases q1h until ph 7. Diabetic ketoacidosis dka is a rare yet potentially. Patient care orders treatment of diabetic ketoacidosis for adults greater than 18 years page 3 of 4 orders. Determine the average hourly rate over the last 8 hours in unitshr and multiply by 24 hours b. Pdf the joint british diabetes societies guidelines for the management of diabetic. Diabetic ketoacidosis dka critical care guideline two bag.
A persons breath may develop a specific fruity smell. Compliance with the 2006 ada hyperglycemic crises in adult patients with diabetes clinical guidelines was low for treatment of dka in a sample of adult patients. Dka guideline for diagnosis hhs guideline for diagnosis. Common dka precipitants include infection, mi or insulin omission. Guidelines for the management of patients with dka and hhs. Management of diabetic ketoacidosis in adults age 16 years. Intensive insulin management remains the only option for effective treatment of. Diabetic ketoacidosis dka is biochemically defined as a venous ph 200 mgdl 11 mmoll together with ketonemia, glucosuria, and ketonuria. Due to its increasing incidence and economic impact related to the treatment and associated morbidity, effective management and prevention is key. Developmental outcomes following neurologic deterioration during dka have varied from no sequelae.
To transfer from iv to sc, continue iv insulin infusion for 1 to 2 hours after sc insulin is begun to. The major modifications from the previous version dated 20151007 of the protocol include. Regional practice guidelines for diabetic ketoacidosis dka. The management of diabetic ketoacidosis in children. Dka with acidosis and ketosis, and the calculated serum osmolality greater than 320mosmkg then mixed hhs dka is present. Allow 30 minute overlap after 1st injection of rapidacting insulin before the insulin infusion is stopped.
Adult dka management these recommendations do not take into account individual patient situations, and do not substitute for clinical judgment. Current treatment of dka mspace university of manitoba. Diabetic ketoacidosis protocol call consultant on admission 1. Diabetic ketoacidosis dka management algorithm adult. Guidelines for the management of patients with dka and hhs in.
Pediatric dka protocol this protocol is intended as a guide individual patient modifications may be necessary. According to the canadian dka guidelines, there are. It occurs when absolute or relative insulin deficiency inhibits the ability of glucose to enter cells for utilization as metabolic fuel, the result being that the liver rapidly breaks down fat. Dka at diagnosis is more common in children 500 mlhour 0.
Pdf joint british diabetes societies guideline for the management. Dka at diagnosis is more common in children dka stage oob, dc foley and unneeded intravenous lines if eating reliably can discontinue iv dextrose if not volume or free water depleted discontinue iv fluids glargine. Dka treatment should be modified after discussion with intensive care consultant and endocrinologist oncall. Treatment recommendations university of missouri marie e.
The goal of treatment is for all parameters to return to normal over 36 to 48 hours. Diabetic ketoacidosis dka, a lifethreatening complication of type 1 diabetes, is preventable but errors in the way it is managed are common and and associated with significant morbidity and mortality. Jun 30, 2014 diabetic ketoacidosis dka is a rare yet potentially fatal hyperglycemic crisis that can occur in patients with both type 1 and 2 diabetes mellitus. No yes cbg is now greater than 4mmoll nb give once only. Diabetic ketoacidosis dka is a serious complication of diabetes where large amounts of ketones an acidic substance are produced and accumulate in the blood making the blood more acidic. Phase type of fluid rate iv regular insulin endpointgoal 0. In 2009, there were 140,000 hospitalizations for diabetic ketoacidosis dka with an average length of stay of 3. Diabetic ketoacidosis dka and hyperosmolar hyperglycemic state hhs, also known as hyperosmotic hyperglycemic nonketotic state hhnk are two of the most serious acute complications of diabetes.
G dka diabetic ketoacidosis g hhs hyperosmolar hyperglycemic state g mixed 2. Review of evidence for adult diabetic ketoacidosis management. Patient care orders treatment of diabetic ketoacidosis for. To provide a guideline for management of the patient presenting with dka. Prebreakfast administer both glargine and aspart dose according to premeal aspart order set. Identify and treat the cause of the dka precipitation. They are part of the spectrum of hyperglycemia, and each represents an extreme in the spectrum. Guidelines 2 confirmation of dka diagnosis 3 treatment goals 3 insulin 4 iv fluids and hydration 4 dextrose,sodium, bicarbonate, potassium 6 monitoring parameters 7 4. Diabetic ketoacidosis and hyperglycemic hyperosmolar state asped. Diabetic ketoacidosis dka remains the leading cause of death in children with type i diabetes mellitus. Goals of treatment replace volume deficit correct ketosis and acidosis with continuous insulin replace electrolyte deficits replace free water deficit prevent hypoglycemia determine inciting condition for the dka correct hyperglycemia secondary goal when dka resolved. Diabetic ketoacidosis dka is a rare yet potentially fatal hyperglycemic crisis that can occur in patients with both type 1 and 2 diabetes mellitus. Initial management of the pediatric patient page 1. Review of evidence for adult diabetic ketoacidosis management protocols.
Change in blood glucose trend insulin infusion titration. Placement of a central venous catheter eliminates the need for frequent venipuncture to monitor blood glucose, electrolytes, and venous blood gases. Various potentially lifethreatening fluid and electrolyte changes can occur with dka. Patient is alert and demonstrates interest in eating b.
Mean amount of insulin used and duration of treatment till resolution of dka were 6. Diabetic ketoacidosis dka is a potentially lifethreatening complication of diabetes mellitus. Criteria and overview pathophysiology of dka explanation of evidence ratings summary of version changes inclusion criteria dka is defined as need all 3 criteria. No other identifiable cause for dka all orders and protocol assumes previous treatment in the ed setting ed work up must include vbg, cmp and evaluation for other causes of dka mildmoderate dka as defined by ph 7. Combining lr with an equal volume of d10w effectively creates a solution of d5. Diabetic ketoacidosis dka is an acute, major, lifethreatening complication of diabetes characterized by hyperglycemia, ketoacidosis, and ketonuria. Near patient testing for 3betahydroxybutyrate is now readily available for the monitoring of the abnormal metabolite allowing for a shift away from using glucose levels to drive treatment decisions in the management of dka. Patient care orders treatment of diabetic ketoacidosis. Dka hhs ispad consensus guidelines pediatric diabetes. Decrease rate of change of insulin infusion by 50% if blood glucose decreases by 100 mgdl per hour and notify physician. Its main characteristics are hyperglycemia, ketosis, acidosis and dehydration in case of profound insulin deficiency in diabetics. Changesdeletions to be initialed by prescriber first 24 hours once dka diagnosis confirmed. Diabetic ketoacidosis is characterized by a serum glucose level greater than 250 mg per dl, a ph less than 7.
Insulin infusion should be continued until acidosis has resolved, as demonstrated by ph 7. Pdf evaluation of the treatment of diabetic ketoacidosis in the. The uptake of a new dka protocol was studied in a retrospective audit of 46 dka episodes over a 4month period in 2008, with adherence rates above 70% in the initial hour table 6, although this declined after 1 h following commencement of treatment, resulting in incorrect fluids being administered and neglect in monitoring electrolytes. Acute myocardial infarction, cva, trauma, sepsis protracted vomiting. This is based on the assumption that this would efficiently suppress ketogenesis and reverse acidosis. Uptodate, electronic clinical resource tool for physicians and patients that provides information on adult primary care and internal medicine, allergy and immunology, cardiovascular medicine, emergency medicine, endocrinology and diabetes, family medicine, gastroenterology and hepatology, hematology, infectious diseases, nephrology and. By placing treatment strategies into protocols, such delays can.
Until recently, management of dka has focussed on lowering the elevated blood glucose with fluids and insulin, using arterial ph and serum bicarbonate to assess metabolic improvement. Review of evidence for adult diabetic ketoacidosis. Diabetic ketoacidosis dka is a serious hormonal disorder requiring emergency therapy. Diabetes ketoacidosis dka orders clinical institute. The management of diabetic ketoacidosis in adults our. Omission of insulin is the most common precipitant of dka.
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