Management of diabetic ketoacidosis and hyperosmolar. Because there is considerable individual variability in presentation. Divisions of pediatric emergency medicine and endocrinology date of approval. Development and implementation of a hyperglycemic emergency. Blood glucose is routinely checked at the bedside, but portable ketone meters now also allow bedside measurement of blood ketones 3betahydroxybutyrate. Treatment of diabetic ketoacidosis with subcutaneous. Diabetic ketoacidosis dka is an acute metabolic complication of diabetes that is potentially fatal and requires prompt medical attention for successful treatment. Understand the etiology of diabetic ketoacidosis dka. It has been benchmarked against joint british diabetes societies jbds guidance, to provide guidance on the clinical management of dka in line with best practice guidelines. Diabetic ketoacidosis dka represents a profound insulindeficient state characterized by hyperglycemia 200 mgdl 11. Initiate dka order set phase i in pregnancy utilize ob dka order set. Diabetic ketoacidosis and hyperglycemic hyperosmolar state.
Dka is responsible for more than 500,000 hospital days per year 1,2 at an estimated annual direct medical expense and indirect cost of 2. Trusts need to ensure that they have local protocols in place, which allow for the. Recommendations concerning fluid management have been modified to reflect recent findings from a randomized controlled clinical trial showing no difference in cerebral injury in patients rehydrated at different rates with either 0. In the last decade, however, there has been a change in the way patients with dka present clinically and in addition there has been rapid development of nearpatient testing. Insulin infusion should be continued until acidosis has resolved, as demonstrated by ph 7. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome hhs are life threatening complications that occur in patients with diabetes. This algorithm has been developed for md anderson using a multidisciplinary approach considering circumstances particular to md andersons. When your cells dont get the glucose they need for energy, your body begins to burn fat for energy, which produces ketones. Practice guidelines resources american diabetes association. This is an important advance in the management of dka sheikhali 2008, bektas 2004.
Dka at diagnosis is more common in children management of an episode of dka is not complete until an attempt has been made to identify and treat the cause. It is characterised by absolute insulin deficiency and is the most common acute hyperglycaemic complication of type 1 diabetes mellitus. The current management protocol at chbah was observed, i. These guidelines recommend that management is based on bedside monitoring of patients with dka. Diabetic ketoacidosis dka is the metabolic abnormality of type 1 diabetes. Joint british diabetes societies inpatient care group.
Specific guidelines exist for the management of dka in children. Acute management of diabetic ketoacidosis in adults this protocol is for the acute management of diabetic ketoacidosis in patients 16 years and over. Diabetic ketoacidosis dka critical care guideline two bag system inclusion criteria definition of dka. Objective in this prospective, randomized, open trial, we compared the efficacy and safety of aspart insulin given subcutaneously at different time intervals to a standard lowdose intravenous iv infusion protocol of regular insulin in patients with uncomplicated diabetic ketoacidosis dka. Diabetic ketoacidosis american academy of pediatrics. The 2009 american diabetes association ada position statement on hyperglycaemic emergencies in adult patients with diabetes details the management of diabetic ketoacidosis dkaand hyperosmolar. Management of diabetic ketoacidosis in adults clinical. A potential complication of treatment with sodiumglucose cotransporter 2 inhibition. Diabetic ketoacidosis dka care guidelines emergency department management inclusion criteria definition of dka. In the united states, more than 100,000 individuals are hospitalized each year for dka and the mortality rate is 2% to 5%. Dka treatment protocol barbara davis center for childhood.
Aug 01, 2019 diabetic ketoacidosis dka occurs when there is a relative or absolute decrease in circulating insulin levels in relation to an increase in counterregulatory hormone levels. In addition to timely identification of the precipitating cause, the first step in acute management of these disorders includes aggressive administration of intravenous fluids with appropriate replacement of electrolytes primarily potassium. After completing this article, readers should be able to. Diabetic ketoacidosis dka and the hyperosmolar hyperglycemic state hhs are the two most serious acute metabolic complications of diabetes. Diabetic ketoacidosis dka critical care guidelines continued transition to sq insulin guidelines for transition 1 ph 7. Sep 15, 20 in the dkahhs management protocol, regular insulin administered by i. Children and adolescents with dka should be managed in a unit that has. Standards of medical care in diabetes2019 abridged for. One approach to delivering best clinical practices is development of inpatient standardized protocols for dka management. Download pdf of the guidelines for diabetes in pregnancy.
Decrease rate of change of insulin infusion by 50% if blood glucose decreases by 100 mgdl per hour and notify physician. Stanford hospital and clinics glycemic control of diabetes mellitus stanford coordinated care glycemic control of diabetes mellitus protocol stanford coordinated care page 1 purpose. Intravenous fluids are essential in management of dka. Dka guideline for diagnosis hhs guideline for diagnosis. The management of diabetic ketoacidosis in adults our. Guidelines for the management of patients with dka and hhs.
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. It is treated commonly in the intensive care unit icu, even though clinical data from many studies support management in regular medicalsurgical wards, avoiding expensive critical care unit costs and preventing bed crisis in these higher level. Blood glucose bg 200 mgdl acidosis bicarbonate dka, and when patient is able to eat, initiate a multidose insulin regimen. To address these issues the joint british diabetes societies jbds, supported by nhs diabetes, has produced this revision of the 2010 guidance developed by a multidisciplinary group of practicing specialists with considerable experience in this area. To enhance collaborative patient care by referral of patients with a diagnosis of type 1 or type2 diabetes dm to be comanaged by the clinical pharmacist, pharmacy resident or rn following this. Clinical information systems using registries that can provide patientspeci. Insulin protocols for managing dka critical care veterinary. Diabetic ketoacidosis and hyperosmolar hyperglycemic. Weve helped produce the management of diabetic ketoacidosis in adults, pdf, 4mb published by the joint british diabetes societies inpatient car. Dka is the leading cause of death in children with type 1 diabetes 1, 2 and accounts for a significant proportion of admissions in adult patients with type 1 or type 2 diabetes 1, 3. Ispad 2009, mcgeoch 2007, savage 2006, bsped 2004, kitabchi 2009. Guidelines for the management of patients with dka and hhs in. Objectives in 20, the association, now diabetes canada, published national clinical practice guidelines for the effective management of diabetic ketoacidosis and hyperosmolar hyperglycemic.
Change in blood glucose trend insulin infusion titration. Understand the basic clinical presentation, diagnostic tests, and management of dka. Blood glucose bg 200 mgdl acidosis bicarbonate management diabetic ketoacidosis dka in adults and adolescents admitted under adult medical care only. Diabetic ketoacidosis dka management algorithm adult. Arterial blood gas results rarely influence emergency physician management of patients. In patients aged 16 years presenting with dka, the management of dka should be discussed with relevant paediatric staff. Adult dka management these recommendations do not take into account individual patient situations, and do not substitute for clinical judgment. Diabetic ketoacidosis is characterized by a serum glucose level greater than 250 mg per dl, a ph less than 7. Research design and methods a total of 45 consecutive patients admitted with dka. Decision support basing care on evidencebased, effective care guidelines 4.
Diabetic ketoacidosis dka is the most common hyperglycemic emergency in patients with diabetes. Table 1 outlines the diagnostic criteria for dka and hhs. Jun 30, 2014 dka management protocols in clinical care. Sk226 0812 diabetic ketoacidosis management protocol. Comparison of blood gas and acidbase measurements in arterial and venous blood samples in patients with uremic acidosis and diabetic ketoacidosis in the emergency room. This protocol is to be used for the management of diabetic ketoacidosis dka in adults over the age of 16. To transfer from iv to sc, continue iv insulin infusion for 1 to 2 hours after sc insulin is begun to. In response to this imbalance, normal physiologic mechanisms are exaggerated, resulting in hyperglycemia, hyperosmolality, ketosis, and acidosis. They are part of the spectrum of hyperglycemia, and each represents an extreme in the spectrum. Management of acute diabetic ketoacidosis dka below is the link to the care pathway for the management of diabetic ketoacidosis in adults. Hyperglycemic crises in adult patients with diabetes. Hyperglycemic hyperosmolar state insulin titration iii. Diabetic ketoacidosis dka care guidelines emergency. Nurse practitioners are well positioned to promote patient education, self management, and individualized patient care.
Clinicians should understand the appropriate management and risks associated with treatment of children with diabetic ketoacidosis. Those with severe dka have a much higher mortality and risk of complications. The joslin guideline for detection and management of diabetes in pregnancy is designed to assist internal medicine specialists, endocrinologists and obstetricians in individualizing the care of and setting goals for women with preexisting diabetes who are pregnant or planning pregnancy. If protocol contraindicated or not ordered, notify physician. This article outlines updates in the clinical management of. Whatyoushouldknow diabeticketoacidosis dkaisacommon,serious,andpreventablecomplicationoftype1diabetes,withamortalityof35%. The 2009 american diabetes association ada position statement on hyperglycaemic emergencies in adult patients with diabetes details the management of diabetic ketoacidosis dka and hyperosmolar hyperglycaemia state. Experienced nursing staff trained in dka management written guidelines for dka management access to laboratories that can provide frequent and timely measurements of biochemical variables.
Patient is alert and demonstrates interest in eating b. Place of management the child with dka should receive care in a unit that has. If there is no improvement as above, then the friii rate should be increased see management of dka, appendix 4 3. Clinicians should use the protocol they are most comfortable using. Management of diabetic ketoacidosis in children and. Glycemic control of diabetes mellitus protocol stanford coordinated care page 1 purpose. Identify and treat the cause of the dka precipitation. Treatment of diabetic ketoacidosis with subcutaneous insulin.
Diabetic ketoacidosis symptoms, diagnosis and treatment. In addition to rehydration, fluids will help lower plasma glucose by dilution and increasing glomerular filtration rate. Management of diabetic ketoacidosis in adults age 16. Joint british diabetes societies guideline for the management of diabetic ketoacidosis. Emergency department management clinical practice guideline cpg protocol approved by. Diabetic ketoacidosis dka critical care guideline two bag. In the last decade, however, there has been a change in the way patients with dka present clinically and in addition there has been rapid development of nearpatient testing technology. Diabetic ketoacidosis dka management algorithm adult patients.
The protocol for the management of patients with dka is presented in figure 1. Dka onset and recurrence can largely be prevented through patient education. Diabetic ketoacidosis and hyperglycemic hyperosmolar state wolfsdorf ji, allgrove j, craig me, edge j, glaser n. Prebreakfast administer both glargine and aspart dose according to premeal aspart order set. Diabetic ketoacidosis dka critical care guideline two. 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. Diabetic ketoacidosis can occur in persons of all ages, with 14 percent of cases occurring in.
Dka guideline for diagnosis hhs guideline for diagnosis plasma glucose 250 mgdl arterial ph 12 plasma glucose 600 mgdl serum osmolality 320 mosmkg arterial ph 7. Dka without a preceding febrile illness or gastroenteritis in a patient with known diabetes is almost always the result of psychosocial problems and failure to appropriately administer insulin. The 2020 standards of medical care in diabetes includes all of adas current clinical practice recommendations and is intended to provide clinicians, patients, researchers, payers, and others with the components of diabetes care, general treatment goals, and tools to evaluate the quality of care. Label or block print skmr009 aug 12 ijmrn gender surname given names d. Diabetic ketoacidosis dka is an emergency for people with diabetes characterized by hyperglycemia, metabolic acidosis, and ketosis. Perhaps even more importantly, because dka is a multiday and therefore multidoctor management disease, the team of doctors who manage inpatients should become familiar with more than one protocol, and have a group decision about which protocol s you will use in your hospital. Phase type of fluid rate iv regular insulin endpointgoal 0. Criteria and overview pathophysiology of dka explanation of evidence ratings summary of version changes inclusion criteria dka is defined as need all 3 criteria. Management of feline diabetic ketoacidosis wsava20 vin. The management of dka requires a full complement of hospital, emergency, and intensive care services.
Management of diabetic ketoacidosis in adults queensland health. Guidelines and position statements from medical organisations are widely used by clinicians to guide the care of their patients. Flow chart for diabetic ketoacidosis in adults management of. Most cases of dka can be prevented by using an effective diabetes management plan that includes patient selfcare. Access to laboratory services for frequent and timely evaluation of biochemical variables.
Management of diabetic ketoacidosis in adults age 16 years. Management of diabetic ketoacidosis article pdf available in the indian journal of pediatrics 785. Diabetic ketoacidosis carries a significant mortality rate and close monitoring is essential. 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. Community resources and policies identifying or developing resources to support healthy lifestyles 6. Guidelines and position statements from medical the care of their patients. Near patient testing for the ketones is now readily available for monitoring allowing for a shift away from using glucose levels to drive treatment decisions in the management of dka.
Experienced nursing staff trained in monitoring and management of dka in children and adolescents. Guidelines for management of diabetic ketoacidosis. Introduction hhs and dka are not mutually exclusive but rather two conditions that both result from some degree of insulin deficiency. The time to resolution of dka, complications and deaths were recorded. Diabetic ketoacidosis is a complication for some patients with insulindependent diabetes mellitus as well as for noninsulin dependent. Management of diabetic ketoacidosis in adults clinical guideline v4.
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