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Dka Algorithm

Emergency Department

Emergency Department

This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use. TITLE: GASHA Pediatric Diabetic Ketoacidosis (DKA) Physician and Nursing Protocol NUMBER: 1-450 Applies to: All Nursing Staff and Physicians Caring for Children with DKA POLICY Diabetic Ketoacidosis (DKA) involves a combination of hyperglycemia, acidosis, and ketones. It is diagnosed when: 1. the blood glucose is greater than or equal to 11 mmol/L 2. capillary pH is less than or equal to 7.3 and/or capillary bicarbonate is less than or equal to 15 mmol/L 3. ketones are present in the blood and/or urine (see below). It usually takes days to develop DKA, but it can take hours in children with acute illness, insulin omission or insulin pump failure. Causes of DKA Include: • undiagnosed type 1 diabetes • insulin omission or manipulation • inadequate insulin dosing and monitoring during periods that significantly increase insulin needs: (illness, infection, major stress, puberty, pregnancy) • insulin pump or infusion site malfunction or misuse Signs and symptoms Include: • polyuria • polydipsia • dehydration • weight loss • lethargy • nausea, vomiting and abdominal pain • fruity or acetone smelling breath • flushed face • confusion • hyperventilation and Kussmaul breathing (rapid, deep, sighing – mouth breathing) • ↑ heart rate and ↑ respirations, and ↓ blood pressure Acute dehydration must be treated with IV fluid replacement. Overhydration, correcting the hyperglycemia too quickly, the use of insulin in the first 1 – 2 hours of fluid therapy, and the use of bicarbonate ha Continue reading >>

Management Of Adult Diabetic Ketoacidosis

Management Of Adult Diabetic Ketoacidosis

Go to: Abstract Diabetic ketoacidosis (DKA) is a rare yet potentially fatal hyperglycemic crisis that can occur in patients with both type 1 and 2 diabetes mellitus. Due to its increasing incidence and economic impact related to the treatment and associated morbidity, effective management and prevention is key. Elements of management include making the appropriate diagnosis using current laboratory tools and clinical criteria and coordinating fluid resuscitation, insulin therapy, and electrolyte replacement through feedback obtained from timely patient monitoring and knowledge of resolution criteria. In addition, awareness of special populations such as patients with renal disease presenting with DKA is important. During the DKA therapy, complications may arise and appropriate strategies to prevent these complications are required. DKA prevention strategies including patient and provider education are important. This review aims to provide a brief overview of DKA from its pathophysiology to clinical presentation with in depth focus on up-to-date therapeutic management. Keywords: DKA treatment, insulin, prevention, ESKD Go to: Introduction In 2009, there were 140,000 hospitalizations for diabetic ketoacidosis (DKA) with an average length of stay of 3.4 days.1 The direct and indirect annual cost of DKA hospitalizations is 2.4 billion US dollars. Omission of insulin is the most common precipitant of DKA.2,3 Infections, acute medical illnesses involving the cardiovascular system (myocardial infarction, stroke) and gastrointestinal tract (bleeding, pancreatitis), diseases of the endocrine axis (acromegaly, Cushing’s syndrome), and stress of recent surgical procedures can contribute to the development of DKA by causing dehydration, increase in insulin counter-regulatory hor Continue reading >>

Type 1 Diabetes In Adults: Diagnosis And Management

Type 1 Diabetes In Adults: Diagnosis And Management

High blood glucose (hyperglycaemia) that is not treated can lead to a serious condition called diabetic ketoacidosis (or DKA for short). It is caused by the build‑up of harmful ketones in the blood. People with type 1 diabetes are at risk of DKA. You may be advised to test for ketones in your blood or urine as part of sick-day rules. Your blood ketones may be measured by a healthcare professional if it is thought you might have DKA. If you have DKA you will need emergency treatment in hospital by a specialist care team. This will include having fluids through a drip. Questions to ask about DKA Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Diabetic Ketoacidosis is a complication of new or existing Type 1 Diabetes. Pediatric DKA may be complicated by cerebral edema and due to this risk, is treated differently than adult DKA. Health care providers must follow a published pediatric-specific protocol when treating pediatric DKA. We have chosen 3 examples of such protocols: a general treatment algorithm from the Canadian Diabetes Association, a detailed treatment algorithm from BC Children's Hospital (English) and a detailed treatment algorithm from Centre hospitalier universitaire Sainte-Justine (French). Each pediatric hospital in Canada will have a protocol that they follow, thus early communication with the diabetes specialist at your pediatric referral site is a key element of the management of these patients. Continue reading >>

Use Of A Computer-based Insulin Infusion Algorithm To Treat Diabetic Ketoacidosis In The Emergency Department

Use Of A Computer-based Insulin Infusion Algorithm To Treat Diabetic Ketoacidosis In The Emergency Department

Abstract Background: Efforts at improving quality metrics in diabetes focus on minimizing adverse events and avoiding re-admissions to the hospital. Our experience with Glucommander™ (Glytec, Greenville, SC), a cloud-based insulin management software system, suggested that its use in the emergency department (ED) would be useful in treating patients with mild diabetic ketoacidosis (DKA). Materials and methods: Thirty-five patients seen in the ED with hyperglycemic crises and diagnosed with DKA during one calendar year were reviewed. A retrospective chart review was performed on patients who were placed on Glucommander™ for DKA management. We excluded patients with significant acidosis or concomitant medical illnesses. Results: Initial average capillary glucose level was 487 ± 68 mg/dL, average time to target glucose was 5 h 11 min, and rate of hypoglycemia (blood glucose level <70 mg/dL) was less than 0.3%. Sixteen patients treated with the protocol were discharged from the ED directly, and 19 were admitted. Patients were maintained for an average of 14 ± 1 h on the Glucommander™ protocol. There was a significantly higher anion gap (P = 0.002) and lower serum bicarbonate level (P = 0.006) in the admitted group. We found very low evidence of re-admission (6%) within 30 days of discharge from the ED for DKA patients. No significant glucose-related adverse events were noted. Conclusions: Use of Glucommander™ for guiding the insulin treatment of mild DKA in the ED can decrease admissions to the hospital for DKA by 45%. Low rates of hypoglycemia make this an option to improve efficiency of utilization of inpatient hospital beds. The cost savings for nonadmissions were estimated at $78,000 over the 12 months of the study. Our results suggest that Glucommander™ is Continue reading >>

Hyperglycemic Crises In Adult Patients With Diabetes

Hyperglycemic Crises In Adult Patients With Diabetes

Diabetic ketoacidosis (DKA) and the hyperosmolar hyperglycemic state (HHS) are the two most serious acute metabolic complications of diabetes. 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 2.4 billion USD (2,3). Table 1 outlines the diagnostic criteria for DKA and HHS. The triad of uncontrolled hyperglycemia, metabolic acidosis, and increased total body ketone concentration characterizes DKA. HHS is characterized by severe hyperglycemia, hyperosmolality, and dehydration in the absence of significant ketoacidosis. These metabolic derangements result from the combination of absolute or relative insulin deficiency and an increase in counterregulatory hormones (glucagon, catecholamines, cortisol, and growth hormone). Most patients with DKA have autoimmune type 1 diabetes; however, patients with type 2 diabetes are also at risk during the catabolic stress of acute illness such as trauma, surgery, or infections. This consensus statement will outline precipitating factors and recommendations for the diagnosis, treatment, and prevention of DKA and HHS in adult subjects. It is based on a previous technical review (4) and more recently published peer-reviewed articles since 2001, which should be consulted for further information. Recent epidemiological studies indicate that hospitalizations for DKA in the U.S. are increasing. In the decade from 1996 to 2006, there was a 35% increase in the number of cases, with a total of 136,510 cases with a primary diagnosis of DKA in 2006—a rate of increase perhaps more rapid than the overall increase in the diagnosis of diabetes (1). Most patients with DKA were between the ages of 18 and 44 years (56%) and 45 and 65 years (24%), with only 18% of patie Continue reading >>

Diabetes Mellitus

Diabetes Mellitus

See also: Background: Diabetic ketoacidosis (DKA) is the combination of hyperglycemia, metabolic acidosis, and ketonaemia. It may be the first presentation for a child with previously undiagnosed diabetes. It can also be precipitated by illness, or poor compliance with taking insulin. All patients presenting with a blood glucose level (BGL) ≥ 11.1mmol/l should have blood ketones tested on a capillary sample using a bedside OptiumTM meter. If this test is positive (>0.6 mmol/l), assess for acidosis to determine further management. Urinalysis can be used for initial assessment if blood ketone testing is not available. The biochemical criteria for DKA are: 1. Venous pH < 7.3 or bicarbonate <15 mmol/l 2. Presence of blood or urinary ketones If ketones are negative, or the pH is normal in the presence of ketones, patients can be managed with subcutaneous (s.c.) insulin (see ' new presentation, mildly ill' below). Assessment of children and adolescents with DKA 1. Degree Of Dehydration (often over-estimated) None/Mild ( < 4%): no clinical signs Moderate (4-7%): easily detectable dehydration eg. reduced skin turgor, poor capillary return Severe(>7%): poor perfusion, rapid pulse, reduced blood pressure i.e. shock 3. Investigations Venous blood sample (place an i.v. line if possible as this will be needed if DKA is confirmed) for the following: FBE Blood glucose, urea, electrolytes (sodium, potassium, calcium, magnesium, phosphate) Blood ketones (bedside test) Venous blood gas (including bicarbonate) Investigations for precipitating cause: if clinical signs of infection consider septic work up including blood culture For all newly diagnosed patients: Insulin antibodies, GAD antibodies, coeliac screen (total IgA, anti-gliadin Ab, tissue transglutaminase Ab) and thyroid function Continue reading >>

Episode 63 – Pediatric Dka

Episode 63 – Pediatric Dka

Pediatric DKA was identified as one of key diagnoses that we need to get better at managing in a massive national needs assessment conducted by the fine folks at TREKK – Translating Emergency Knowledge for Kids – one of EM Cases’ partners who’s mission is to improve the care of children in non-pediatric emergency departments across the country. You might be wondering – why was DKA singled out in this needs assessment? It turns out that kids who present to the ED in DKA without a known history of diabetes, can sometimes be tricky to diagnose, as they often present with vague symptoms. When a child does have a known history of diabetes, and the diagnosis of DKA is obvious, the challenge turns to managing severe, life-threatening DKA, so that we avoid the many potential complications of the DKA itself as well as the complications of treatment – cerebral edema being the big bad one. The approach to these patients has evolved over the years, even since I started practicing, from bolusing insulin and super aggressive fluid resuscitation to more gentle fluid management and delayed insulin drips, as examples. There are subtleties and controversies in the management of DKA when it comes to fluid management, correcting serum potassium and acidosis, preventing cerebral edema, as well as airway management for the really sick kids. In this episode we‘ll be asking our guest pediatric emergency medicine experts Dr. Sarah Reid, who you may remember from her powerhouse performance on our recent episodes on pediatric fever and sepsis, and Dr. Sarah Curtis, not only a pediatric emergency physician, but a prominent pediatric emergency researcher in Canada, about the key historical and examination pearls to help pick up this sometimes elusive diagnosis, what the value of serum Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Authors Runa Acharya, MD, University of Iowa-Des Moines Internal Medicine Residency Program at UnityPoint Health, Des Moines, IA Udaya M. Kabadi, MD, FACP, FRCP(C), FACE, Veteran Affairs Medical Center and Broadlawns Medical Center, Des Moines, IA; Des Moines University of Osteopathic Medicine, Iowa City; and University of Iowa Carver College of Medicine, Iowa City; Adjunct Professor of Medicine and Endocrinology, University of Iowa, Iowa City, and Des Moines University, Des Moines Peer Reviewer Jay Shubrook, DO, FAAFP, FACOFP, Professor, Primary Care Department, Touro University, College of Osteopathic Medicine, Vallejo, CA Statement of Financial Disclosure To reveal any potential bias in this publication, and in accordance with Accreditation Council for Continuing Medical Education guidelines, Dr. Kabadi (author) reports he is a consultant and on the speakers bureau for Sanofi. Dr. Shubrook (peer reviewer) reports he receives grant/research support from Sanofi and is a consultant for Eil Lilly, Novo Nordisk, and Astra Zeneca. Dr. Acharya (author) reports no financial relationships relevant to this field of study. Continue reading >>

Use Of A Computer-based Insulin Infusion Algorithm To Treat Diabetic Ketoacidosis In The Emergency Department

Use Of A Computer-based Insulin Infusion Algorithm To Treat Diabetic Ketoacidosis In The Emergency Department

Diabetes Technology & Therapeutics Authors Jagdeesh Ullal,1 Raymie McFarland,2 Margaret Bachand,3 Joseph Aloi4 Abstract Background Efforts at improving quality metrics in diabetes focus on minimizing adverse events and avoiding re-admissions to the hospital. Our experience with Glucommander (Glytec, Greenville, SC), a cloud-based insulin management software system, suggested that its use in the emergency department (ED) would be useful in treating patients with mild diabetic ketoacidosis (DKA). Materials and Methods Thirty-five patients seen in the ED with hyperglycemic crises and diagnosed with DKA during one calendar year were reviewed. A retrospective chart review was performed on patients who were placed on Glucommander for DKA management. We excluded patients with significant acidosis or concomitant medical illnesses. Results Initial average capillary glucose level was 487 + 68mg/dL, average time to target glucose was 5 h 11min, and rate of hypoglycemia (blood glucose level < 70mg/dL) was less than 0.3%. Sixteen patients treated with the protocol were discharged from the ED directly, and 19 were admitted. Patients were maintained for an average of 14 + 1 h on the Glucommander protocol. There was a significantly higher anion gap (P = 0.002) and lower serum bicarbonate level (P= 0.006) in the admitted group. We found very low evidence of re-admission (6%) within 30 days of discharge from the ED for DKA patients. No significant glucose-related adverse events were noted. Conclusions Use of Glucommander for guiding the insulin treatment of mild DKA in the ED can decrease admissions to the hospital for DKA by 45%. Low rates of hypoglycemia make this an option to improve efficiency of utilization of inpatient hospital beds. The cost savings for nonadmissions were estimate Continue reading >>

M A N A G E M E N T A N D T R E A T M E N T O F

M A N A G E M E N T A N D T R E A T M E N T O F

This care process model (CPM) was developed by Intermountain Healthcare’s Pediatric Clinical Specialties Program. It provides guidance for identifying and managing type 1 diabetes in children, educating and supporting patients and their families in every phase of development and treatment, and preparing our pediatric patients to transition successfully to adulthood and adult diabetes self-management. This CPM is based on guidelines from the American Diabetes Association (ADA), particularly the 2014 position statement Type 1 Diabetes Through the Life Span, as well as the opinion of local clinical experts in pediatric diabetes.ADA1,CHI Pediatric Type 1 Diabetes C a r e P r o c e s s M o d e l F E B R U A R Y 2 0 1 7 2 0 17 U p d a t e Why Focus on PEDIATRIC TYPE 1 DIABETES? Diabetes in childhood carries an enormous burden for patients and their families and represents significant cost to our healthcare system. In 2008, Intermountain Healthcare published the first CPM on the management of pediatric diabetes with the overall goal of helping providers deliver the best clinical care in a consistent and integrated way. What’s new: • Separate CPMs for type 1 and type 2 pediatric diabetes to promote more- accurate diagnosis and more-focused education and treatment. • Updated recommendations for diagnostic testing, blood glucose control, and follow-up care specifically related to pediatric type 1 diabetes. • A more comprehensive view of treatment for pediatric type 1 diabetes — one that emphasizes psychosocial wellness for patient and family and lays a foundation for better health over the lifespan. • Information and tools to support pediatric type 1 diabetes care by nonspecialist providers — important for coping with the ongoin Continue reading >>

Endocrine And Metabolic 2: Diabetic Ketoacidosis Portal

Endocrine And Metabolic 2: Diabetic Ketoacidosis Portal

Introduction DKA develops as a result of insufficient insulin activity and increased counter-regulatory hormones which result in accumulation of ketones (organic acids) and hyperglycemia. This hyperglycemia causes an osmotic diuresis leading to volume contraction and sodium/potassium losses. DKA is a serious complication with significant mortality for patients with insulin-dependent diabetes mellitus. Under certain stressful conditions (eg, MI or sepsis), even patients with non-insulin-dependent diabetes may develop DKA. Furthermore, DKA may often be the initial manifestation of diabetes, especially in pediatric patients.1 Patient Assessment History. Patients with DKA as the initial manifestation of diabetes often experience weight loss, polyuria, and polydipsia. Initial complaints include nausea, weakness, vomiting, and abdominal pain, (PEDS) particularly in children.1 The abdominal pain is usually vague and non-localized but can mimic an acute abdomen. Often, symptoms have progressed over several days. Other signs and symptoms are associated with the concurrent disease/stress event(s) that precipitated the DKA episode, such as infection (the most likely cause), cardiovascular events, stroke, trauma, pregnancy, and other severe stresses. A detailed history helps in managing this complex disorder. Exam. Patients with severe DKA may exhibit shock or altered level of consciousness/coma. Clinically, the patient is usually severely dehydrated; tachycardia is often present. Tachypnea/hyperventilation (Kussmaul respirations—deep, gasping) may be due to respiratory compensation for metabolic acidosis. Ketosis may cause acetone halitosis (a fruity odor on the breath). Other signs will accompany the associated conditions. Diagnostic Studies. An ECG is useful to identify MI if Continue reading >>

Chapter 11: Diabetic Ketoacidosis In Pregnancy

Chapter 11: Diabetic Ketoacidosis In Pregnancy

Despite recent advances in the evaluation and medical treatment of diabetes in pregnancy, diabetic ketoacidosis (DKA) remains a matter of significant concern. The fetal loss rate in most contemporary series has been estimated to range from 10% to 25%. Fortunately, since the advent and implementation of insulin therapy, the maternal mortality rate has declined to 1% or less. In order to favorably influence the outcome in these high-risk patients, it is imperative that the obstetrician/provider be familiar with the basics of the pathophysiology, diagnosis, and treatment of DKA in pregnancy. DKA is characterized by hyperglycemia and accelerated ketogenesis. Both a lack of insulin and an excess of glucagon and other counter-regulatory hormones significantly contribute to these problems and their resultant clinical manifestations. Glucose normally enters the cell secondary to the effects of insulin. The cell then may use glucose for nutrition and energy production. When insulin is lacking, glucose fails to enter the cell. The cell responds to this starvation by facilitating the release of counter-regulatory hormones, including glucagon, catecholamines, and cortisol. These counter-regulatory hormones are responsible for providing the cell with an alternative substrate for nutrition and energy production. By the process of gluconeogenesis, fatty acids from adipose tissue are broken down by hepatocytes to ketones (acetone, acetoacetate, and β-hydroxybutyrate [BHB] = ketone bodies), which are then used by the body cells for nutrition and energy production (Fig. 11-1). The lack of insulin also contributes to increased lipolysis and decreased reutilization of free fatty acids, thereby providing more substrate for hepatic ketogenesis. A basic review of the biochemistry involving D Continue reading >>

A Unified Hyperglycemia And Diabetic Ketoacidosis (dka) Insulin Infusion Protocol Based On An Excel Algorithm

A Unified Hyperglycemia And Diabetic Ketoacidosis (dka) Insulin Infusion Protocol Based On An Excel Algorithm

Abstract: Objective – An insulin infusion protocol (IIP) was instituted in medical and surgical ICUs for post-cardiac surgery stress hyperglycemia (SH), diabetes hyperglycemia (DH), and DKA. Prior to 2014, Saint Louis University Hospital (SLUH) used a proportionate delivery protocol which required hourly Insulin Infusin Rate (IIR) recalculation based on BG change. A separate protocol was followed for diabetic ketoacidosis (DKA). A unified ICU protocol was designed in 2013 and implemented in 2014 for treatment of DH, DKA, and post-cardiothoracic surgery SH to meet SCIP criteria. The protocol utilized conventional diabetes management techniques, i.e. 1) body weight based, 2) designed with the concept of basal plus correction factor, 3) pre-calculated insulin doses , 4) maximum IIR at higher BG and 6) progressively decreasing IIR as BG approaches designated target range (DTR) to limit hypoglycemia Method - The IIP was assessed during one month for all patients in ICUs. The IIP was developed in Excel and our project is IRB exempt. The IIR is higher at BG >160mg/dL (0.5units/ kg/24 hour, defined as “Phase 1” to lower hyperglycemia), and decreases progressively as BG decline. There is an abrupt decrease in the IIR at a threshold BG of 160mg/dL, (rate 0.3units/kg/ 24hours defined as “Phase 2”, maintenance rate) to sustain BG between a DTR, 120 mg/dL-180 mg/dL. An acceptable target range (ATR) is considered between 100mg/dL-200mg/dL. A correction factor for BG >120mg/dL is added to the IIR by estimating Total Daily Dose (TDD) of insulin. IIR is pre-calculated and stored in the electronic medical record system (EPIC) in weight based columns from 40kg through 150kg with increments of 10 kg. Nurses titrate IIR hourly based only on the current BG. When BG has been in targ Continue reading >>

University Of Zagreb

University Of Zagreb

SCHOOL OF MEDICINE Mohammad Imran Khan Malik A review of the efficacy of the Milwaukee protocol in the treatment of ketoacidosis in pediatric Intensive Care Unit patients at Rebro hospital between 2009-2014. GRADUATE THESIS Zagreb, 2014 UNIVERSITY OF ZAGREB SCHOOL OF MEDICINE Mohammad Imran Khan Malik A review of the efficacy of the Milwaukee protocol in the treatment of ketoacidosis in pediatric Intensive Care Unit patients at Rebro hospital between 2009-2014. GRADUATE THESIS Zagreb, 2014 This graduation paper has been completed at the Department of Paediatrics at the University Hospital Centre Zagreb (Rebro hospital) under the supervision of Dr. sc. Mario Ćuk and was submitted for evaluation during the academic year 2013 /2014. LIST OF TABLES Table 1: DKA laboratory diagnosis criteria Table 2: Classification of DKA. Modified from Kliegman et al. Nelson Textbook of Pediatrics, 2011. Table 3: Table 3: Summary of key data of patients admitted to pediatric ICU at Rebro hospital. LIST OF FIGURES Figure 1: DKA pathogenesis. Figure 2: Ketone bodies: showing formation of negatively charged conjugate bases of the ketoacids. The conjugate bases cause the increased anion gap in DKA metabolic acidosis. Figure 3: Algorithm of key steps in DKA pathophysiology. Colour coded to highlight the two areas that treatment should target: metabolic acidosis and hyperglycemia. Figure 4: True sodium level calculations for glucose levels above 100mg/dL (5.6mmol/L). Figure 5: Goals of DKA management Figure 6: Diabetic ketoacidosis treatment: Milwaukee protocol. Modified from Kliegman et al. Nelson Textbook of Paediatrics. 2011 p.1979 Figure 7: DKA incidence between 1 st January 2009 – 30 th June 2014. LIST OF ABBREVIATIONS DKA ..............Diabetic Ketoacidosis CE...................C Continue reading >>

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