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Dka Diagnosis Criteria Uk

Uk Doctor Calls For Dka Guidelines Revision In Bid To Improve Diagnosis

Uk Doctor Calls For Dka Guidelines Revision In Bid To Improve Diagnosis

A UK doctor has called for an overhaul of guidance related to the diagnosis and management of diabetic ketoacidosis (DKA) in adults. DKA is a complication of type 1 diabetes and, in some cases, latent autoimmune diabetes of adults (LADA), characterised by a lack of insulin aggravated by high blood sugar levels and the build-up of ketone bodies in the blood. In a new editorial written in The Lancet, Dr Ketan Dhatariya, a diabetes and endocrinology consultant based at the Norfolk and Norwich University Hospitals NHS Trust, argues that our national guidance is laconic. He believes that the international recommendations we resort to are largely outdated, and that a number of modifications should be made, highlighting new evidence that has emerged since the American Diabetes Association's (ADA) last position statement on DKA in 2009. Dhatariya's proposed changes include the use of more criteria to define DKA and different management options for short-term complications of DKA. The problem with the diagnosis of DKA, as seen by Dhatariya, is twofold: the blood sugar cut-off point of 13.9 mmol/L to identify DKA is set too high, and DKA is too often diagnosed based on a single risk factor like the disruption of insulin treatment or elevated ketone levels. Drawing from accumulated professional experience, Dhatariya knows that many patients vulnerable to DKA can present with smaller increases in blood sugar levels than this cut-off point after lowering their insulin dose, reducing their food intake, or when ill. By referring to the standardised cut off score of 13.9 mmol/mol, euglycemic DKA (defined as DKA without marked hyperglycemia) seen in patients with gestational diabetes or those treated with SGLT2 inhibitors, can go amiss too. Euglycemic DKA is thought to occur when blood Continue reading >>

The Management Of Diabetic Ketoacidosis In Adults

The Management Of Diabetic Ketoacidosis In Adults

Action 1: Commence 0.9% sodium chloride solution (use large bore cannula) via infusion pump. See Box 2 for rate of fluid replacement Action 2: Commence a fixed rate intravenous insulin infusion (IVII). (0.1unit/kg/hr based on estimate of weight) 50 units human soluble insulin (Actrapid® or Humulin S®) made up to 50ml with 0.9% sodium chloride solution. If patient normally takes long acting insulin analogue (Lantus®, Levemir®) continue at usual dose and time Action 3: Assess patient o Respiratory rate; temperature; blood pressure; pulse; oxygen saturation o Glasgow Coma Scale o Full clinical examination Action 4: Further investigations • Capillary and laboratory glucose • Venous BG • U & E • FBC • Blood cultures • ECG • CXR • MSU Action 5: Establish monitoring regimen • Hourly capillary blood glucose • Hourly capillary ketone measurement if available • Venous bicarbonate and potassium at 60 minutes, 2 hours and 2 hourly thereafter • 4 hourly plasma electrolytes • Continuous cardiac monitoring if required • Continuous pulse oximetry if required Action 6: Consider and precipitating causes and treat appropriately BOX 1: Immediate management: time 0 to 60 minutes (T=0 at time intravenous fluids are commenced) If intravenous access cannot be obtained request critical care support immediately Systolic BP (SBP) below 90mmHg Likely to be due to low circulating volume, but consider other causes such as heart failure, sepsis, etc. • Give 500ml of 0.9% sodium chloride solution over 10-15 minutes. If SBP remains below 90mmHg repeat whilst requesting senior input. Most patients require between 500 to 1000ml given rapidly. • Consider involving the ITU/critical care team. • Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes mellitus.[1] Signs and symptoms may include vomiting, abdominal pain, deep gasping breathing, increased urination, weakness, confusion, and occasionally loss of consciousness.[1] A person's breath may develop a specific smell.[1] Onset of symptoms is usually rapid.[1] In some cases people may not realize they previously had diabetes.[1] DKA happens most often in those with type 1 diabetes, but can also occur in those with other types of diabetes under certain circumstances.[1] Triggers may include infection, not taking insulin correctly, stroke, and certain medications such as steroids.[1] DKA results from a shortage of insulin; in response the body switches to burning fatty acids which produces acidic ketone bodies.[3] DKA is typically diagnosed when testing finds high blood sugar, low blood pH, and ketoacids in either the blood or urine.[1] The primary treatment of DKA is with intravenous fluids and insulin.[1] Depending on the severity, insulin may be given intravenously or by injection under the skin.[3] Usually potassium is also needed to prevent the development of low blood potassium.[1] Throughout treatment blood sugar and potassium levels should be regularly checked.[1] Antibiotics may be required in those with an underlying infection.[6] In those with severely low blood pH, sodium bicarbonate may be given; however, its use is of unclear benefit and typically not recommended.[1][6] Rates of DKA vary around the world.[5] In the United Kingdom, about 4% of people with type 1 diabetes develop DKA each year, while in Malaysia the condition affects about 25% a year.[1][5] DKA was first described in 1886 and, until the introduction of insulin therapy in the 1920s, it was almost univ Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is a serious problem that can occur in people with diabetes if their body starts to run out of insulin. This causes harmful substances called ketones to build up in the body, which can be life-threatening if not spotted and treated quickly. DKA mainly affects people with type 1 diabetes, but can sometimes occur in people with type 2 diabetes. If you have diabetes, it's important to be aware of the risk and know what to do if DKA occurs. Symptoms of diabetic ketoacidosis Signs of DKA include: needing to pee more than usual being sick breath that smells fruity (like pear drop sweets or nail varnish) deep or fast breathing feeling very tired or sleepy passing out DKA can also cause high blood sugar (hyperglycaemia) and a high level of ketones in your blood or urine, which you can check for using home-testing kits. Symptoms usually develop over 24 hours, but can come on faster. Check your blood sugar and ketone levels Check your blood sugar level if you have symptoms of DKA. If your blood sugar is 11mmol/L or over and you have a blood or urine ketone testing kit, check your ketone level. If you do a blood ketone test: lower than 0.6mmol/L is a normal reading 0.6 to 1.5mmol/L means you're at a slightly increased risk of DKA and should test again in a couple of hours 1.6 to 2.9mmol/L means you're at an increased risk of DKA and should contact your diabetes team or GP as soon as possible 3mmol/L or over means you have a very high risk of DKA and should get medical help immediately If you do a urine ketone test, a result of more than 2+ means there's a high chance you have DKA. When to get medical help Go to your nearest accident and emergency (A&E) department straight away if you think you have DKA, especially if you have a high level of ketones in Continue reading >>

Treatment Of Diabetic Ketoacidosis (dka)/hyperglycemic Hyperosmolar State (hhs): Novel Advances In The Management Of Hyperglycemic Crises (uk Versus Usa)

Treatment Of Diabetic Ketoacidosis (dka)/hyperglycemic Hyperosmolar State (hhs): Novel Advances In The Management Of Hyperglycemic Crises (uk Versus Usa)

Abstract Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are diabetic emergencies that cause high morbidity and mortality. Their treatment differs in the UK and USA. This review delineates the differences in diagnosis and treatment between the two countries. Large-scale studies to determine optimal management of DKA and HHS are lacking. The diagnosis of DKA is based on disease severity in the USA, which differs from the UK. The diagnosis of HHS in the USA is based on total rather than effective osmolality. Unlike the USA, the UK has separate guidelines for DKA and HHS. Treatment of DKA and HHS also differs with respect to timing of fluid and insulin initiation. There is considerable overlap but important differences between the UK and USA guidelines for the management of DKA and HHS. Further research needs to be done to delineate a unifying diagnostic and treatment protocol. UK USA Hyperglycemia >30 mmol/L (540 mg/dL) >33.3 mmol/L (600 mg/dL) Hyperosmolarity >320 mOsm/kg >320 mOsm/kg Calculation 2 × Na (mmol/L) + glucose (mmol/L) + urea (mmol/L) 2 × Na (meQ/L) + glucose (mg/dL)/18 + blood urea nitrogen (mg/dL)]/2.8 Lack of acidosis Ketones Low Low pH >7.3 >7.3 Bicarbonate >15 mmol/L >20 mmol/L Mental status changes Present Present Notes Ketan K. Dhatariya is an employee of the UK National Health Service. Ketan K. Dhatariya is the lead author of the Joint British Diabetes Societies Guideline for the management of DKA. He is also on the Clinical Endpoint Adjudication Committee for the Sotagliflozin trials run by Lexicon Pharmaceuticals. Priyathama Vellanki has received consulting fees from Merck & Co. This article does not contain any studies with human or animal subjects performed by any of the authors. Continue reading >>

Updated Feb 2017 J Clayton

Updated Feb 2017 J Clayton

NUH Management of Diabetic Ketoacidosis in Adults (18 years old & over) (Please see the Paediatric guidelines for patients under 18 years) If in doubt, call someone more senior. KETOACIDOSIS CAN KILL. Use in conjunction with the NUH pathway of care for DKA in adults (insulin prescription, administration and monitoring chart). 1. DIAGNOSIS All three required 1. Raised blood glucose>11mmol /L or known diabetes 2. Capillary ketones > 3 mmol/L (or Ketones >2+ in urine) 3. Venous pH < 7.35 or venous bicarb < 15mmol/L 2. ESSENTIAL INVESTIGATIONS Arterial puncture NOT routinely needed  U+E, creatinine, blood glucose  Venous blood gas for bicarbonate, potassium and pH (analyse on machine on B3, ED, HDU, ITU)  ECG/CXR/MSU/blood cultures/pregnancy test depending on clinical suspicion Raised WCC and serum amylase are common in DKA and do not usually suggest pancreatitis. 4. IMMEDIATE TREATMENT START IN EMERGENCY DEPT / ASSESSMENT UNIT OR THEIR CURRENT LOCATION. DELAY IN STARTING TREATMENT MAY BE FATAL. 1. Insert venflon 2. 1L 0.9% sodium chloride infusion over 1hr if systolic BP>90 (If systolic BP<90 give repeated boluses of 500ml 0.9% sodium chloride over 10-15 minutes) 3. Start IV insulin infusion: 50 units human soluble (ACTRAPID®) insulin added to 49.5 mls 0.9% sodium chloride to give a 1 unit/ml solution via syringe driver at 0.1 units/ kg / hr (estimated or actual weight) 3. SEVERITY (Venous bicarbonate or pH) >14 mmol/l or pH >7.3 Mild 10-14 mmol/l or pH 7.1-7.3 Moderate < 10 mmol/l or pH <7.1 Severe 5. TRANSFER NO PATIENT WITH DKA SHOULD BE TRANSFERRED BETWEEN HOSPITALS URGENT CRITICAL CARE/HDU REVIEW if any of: Venous bicarbonate < 10 mmol/l or pH<7.1, drowsy (P or U on AVPU), fluid balance problems, pregnancy, co morbidities, sats<94% on 40% O2, p Continue reading >>

Dka Diagnosis Definitions Need To Be ‘standardised’ – Uk Diabetes Expert

Dka Diagnosis Definitions Need To Be ‘standardised’ – Uk Diabetes Expert

Definitions used to diagnose diabetic ketoacidosis (DKA) should be standardised because current data is based on "very flimsy trial evidence" which is "potentially putting patients in danger", according to a leading expert on the subject. Dr Ketan Dhatariya, a consultant in diabetes and endocrinology at Norfolk and Norwich University Hospitals NHS Foundation Trust, says there is an "urgent" need to ensure all clinicians use the same criteria to define and report DKA. He made the call in an article called Why the definitions used to diagnose diabetic ketoacidosis should be standardised published by Diabetes Research and Clinical Practice. With the concerns about the potentially increased risk of DKA with the use of sodium glucose co-transporter 2 (SGLT-2) inhibitors, Dr Dhatariya said "the issue about how DKA should be defined has become more important". Some trials exploring the impact of SGLT-2s have been based on incomplete and "flawed" data, according to Dr Dhatariya. He said: "Clinicians who practice evidence-based medicine need to rely on good quality data to ensure the decisions they make are based on robust science. However, there is the possibility that the data currently available on the prevalence and management of diabetic ketoacidosis relies on very flimsy trial evidence and that this potentially puts patients in danger." Dr Dhatariya said that the American Diabetes Association guidelines needed to be updated in the face of newer information and that its conclusion that a blood glucose level of 13.9 mmol/L to identify DKA was too high. He also believes that DKA is too often diagnosed based on a single risk factor like the disruption of insulin treatment or elevated ketone levels. Dr Dhatariya concluded: "DKA is a potentially life threatening acute medical em Continue reading >>

The Cost Of Treating Diabetic Ketoacidosis In The Uk: A National Survey Of Hospital Resource Use

The Cost Of Treating Diabetic Ketoacidosis In The Uk: A National Survey Of Hospital Resource Use

Abstract Diabetic ketoacidosis is a commonly encountered metabolic emergency. In 2014, a national survey was conducted looking at the management of diabetic ketoacidosis in adult patients across the UK. The survey reported the clinical management of individual patients as well as institutional factors that teams felt were important in helping to deliver that care. However, the costs of treating diabetic ketoacidosis were not reported. We used a ‘bottom up’ approach to cost analysis to determine the total expense associated with treating diabetic ketoacidosis in a mixed population sample. The data were derived from the source data from the national UK survey of 283 individual patients collected via questionnaires sent to hospitals across the country. Because the initial survey collection tool was not designed with a health economic model in mind, several assumptions were made when analysing the data. The mean and median time in hospital was 5.6 and 2.7 days respectively. Based on the individual patient data and using the Joint British Diabetes Societies Inpatient Care Group guidelines, the cost analysis shows that for this cohort, the average cost for an episode of diabetic ketoacidosis was £2064 per patient (95% confidence intervals: 1800, 2563). Despite relatively short stays in hospital, costs for managing episodes of diabetic ketoacidosis in adults were relatively high. Assumptions made in the calculations did not consider prolonged hospital stay due to comorbidities or costs incurred as a loss of productivity. Therefore, the actual costs to the healthcare system and society in general are likely to be substantially higher. What's new? Diabetic ketoacidosis is a commonly encountered metabolic emergency, but the costs of treating the condition remain unknown in t Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Patient professional reference Professional Reference articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use. You may find the Pre-diabetes (Impaired Glucose Tolerance) article more useful, or one of our other health articles. See also the separate Childhood Ketoacidosis article. Diabetic ketoacidosis (DKA) is a medical emergency with a significant morbidity and mortality. It should be diagnosed promptly and managed intensively. DKA is characterised by hyperglycaemia, acidosis and ketonaemia:[1] Ketonaemia (3 mmol/L and over), or significant ketonuria (more than 2+ on standard urine sticks). Blood glucose over 11 mmol/L or known diabetes mellitus (the degree of hyperglycaemia is not a reliable indicator of DKA and the blood glucose may rarely be normal or only slightly elevated in DKA). Bicarbonate below 15 mmol/L and/or venous pH less than 7.3. However, hyperglycaemia may not always be present and low blood ketone levels (<3 mmol/L) do not always exclude DKA.[2] Epidemiology DKA is normally seen in people with type 1 diabetes. Data from the UK National Diabetes Audit show a crude one-year incidence of 3.6% among people with type 1 diabetes. In the UK nearly 4% of people with type 1 diabetes experience DKA each year. About 6% of cases of DKA occur in adults newly presenting with type 1 diabetes. About 8% of episodes occur in hospital patients who did not primarily present with DKA.[2] However, DKA may also occur in people with type 2 diabetes, although people with type 2 diabetes are much more likely to have a hyperosmolar hyperglycaemic state. Ketosis-prone type 2 diabetes tends to be more common in older, overweight, non-white people with type 2 diabetes, and DKA may be their Continue reading >>

Sglt2 Inhibitors: Updated Advice On The Risk Of Diabetic Ketoacidosis

Sglt2 Inhibitors: Updated Advice On The Risk Of Diabetic Ketoacidosis

Advice for healthcare professionals: When treating patients who are taking a sodium-glucose co-transporter 2 (SGLT2) inhibitor (canagliflozin, dapagliflozin, or empagliflozin): inform them of the signs and symptoms of diabetic ketoacidosis (DKA) – see below – and advise them to seek immediate medical advice if they develop any of these discuss the risk factors for DKA with patients (see below) discontinue treatment with the SGLT2 inhibitor immediately if DKA is suspected or diagnosed do not restart treatment with any SGLT2 inhibitor in patients who experienced DKA during use, unless another cause for DKA was identified and resolved interrupt treatment with the SGLT2 inhibitor in patients who are hospitalised for major surgery or acute serious illnesses; treatment may be restarted once the patient’s condition has stabilised Reports of diabetic acidosis EU medicines regulators have completed a review of DKA associated with SGLT2 inhibitor treatment; this article summarises the review’s recommendations. We published preliminary advice on this in June 2015. SGLT2 inhibitors are licensed for use in adults with type 2 diabetes to improve glycaemic control. Serious, life-threatening, and fatal cases of DKA have been reported in patients taking an SGLT2 inhibitor (canagliflozin, dapagliflozin, or empagliflozin). The EU review concluded that this side effect is rare (affecting between 1 in 1000 and 1 in 10,000 patients). Up to 26 February 2016, we had received 118 Yellow Card reports of DKA and associated reactions in patients taking an SGLT2 inhibitor in the UK. In several cases, blood glucose levels were only moderately elevated (eg <14mmol/L)—representing an atypical presentation for DKA, which could delay diagnosis and treatment. Therefore inform patients of the si Continue reading >>

Factors Associated With The Presence Of Diabetic Ketoacidosis At Diagnosis Of Diabetes In Children And Young Adults: A Systematic Review

Factors Associated With The Presence Of Diabetic Ketoacidosis At Diagnosis Of Diabetes In Children And Young Adults: A Systematic Review

Abstract Objective To identify the factors associated with diabetic ketoacidosis at diagnosis of type 1 diabetes in children and young adults. Design Systematic review. Data sources PubMed, EMBASE, Web of Science, Scopus, and Cinahl and article reference lists. Study selection Cohort studies including unselected groups of children and young adults presenting with new onset type 1 diabetes that distinguished between those who presented in diabetic ketoacidosis and those who did not and included a measurement of either pH or bicarbonate in the definition of diabetic ketoacidosis. There were no restrictions on language of publication. Results 46 studies involving more than 24 000 children in 31 countries were included. Together they compared 23 different factors. Factors associated with increased risk were younger age (for <2 years old v older, odds ratio 3.41 (95% confidence interval 2.54 to 4.59), for <5 years v older, odds ratio 1.59 (1.38 to 1.84)), diagnostic error (odds ratio 3.35 (2.35 to 4.79)), ethnic minority, lack of health insurance in the US (odds ratio 3.20 (2.03 to 5.04)), lower body mass index, preceding infection (odds ratio 3.14 (0.94 to 10.47)), and delayed treatment (odds ratio 1.74 (1.10 to 2.77)). Protective factors were having a first degree relative with type 1 diabetes at the time of diagnosis (odds ratio 0.33 (0.08 to 1.26)), higher parental education (odds ratios 0.4 (0.20 to 0.79) and 0.64 (0.43 to 0.94) in two studies), and higher background incidence of type 1 diabetes (correlation coefficient –0.715). The mean duration of symptoms was similar between children presenting with or without diabetic ketoacidosis (16.5 days (standard error 6.2) and 17.1 days (6.0) respectively), and up to 38.8% (285/735) of children who presented with diabetic ke Continue reading >>

Uk Vs Usa Guidelines For Treating Diabetic Emergencies

Uk Vs Usa Guidelines For Treating Diabetic Emergencies

Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are life-threatening complications of diabetes. UK and USA guidelines for treating diabetic emergencies have some important differences and further research is needed to define the best approach. Diabetes is a common and important medical condition in which the body either cannot produce or becomes insensitive to the hormone insulin. There are two main types of diabetes – Type 1 in which the body’s own immune system attacks the pancreas cells which make insulin, and Type 2 in which body cells become insensitive to insulin, or the pancreas is unable to produce sufficient amounts. Insulin allows body cells to absorb glucose from the circulation, providing them with the energy source they need to function. In people who have diabetes, blood glucose levels rise because glucose is not absorbed into cells – this is called “hyperglycemia”. If left untreated, in the long-term, hyperglycemia can cause damage to the blood vessels and affect organs such as the kidneys and eyes. In the short term, diabetic hyperglycemia may lead to the development of serious chemical imbalances in the body. In type 1 diabetes, since the body is unable to use glucose for energy it begins to use fat as an alternative energy source. This can cause a buildup of toxic acidic byproducts called ketones, which can quickly lead to the development of a condition called diabetic ketoacidosis (DKA). DKA is a life-threatening imbalance in the body’s chemical environment and must be treated urgently. Some people may develop DKA before they are aware that they have type 1 diabetes. Other patients may develop DKA if their insulin treatment is insufficient or becomes unbalanced, due to missed insulin treatment, increased exercise or Continue reading >>

Type 1 Diabetes In Adults: Diagnosis And Management – Nice Guideline (update)

Type 1 Diabetes In Adults: Diagnosis And Management – Nice Guideline (update)

This National Institute for Health and Care Excellence (NICE) guideline covers the care and treatment of adults (aged 18 and over) with type 1 diabetes. Education and information Offer all adults with type 1 diabetes a structured education programme of proven benefit, for example the DAFNE (dose-adjustment for normal eating) programme. Offer this programme 6–12 months after diagnosis. [new 2015] Blood glucose management Support adults with type 1 diabetes to aim for a target HbA1c level of 48 mmol/mol (6.5%) or lower, to minimise the risk of long‑term vascular complications. [new 2015] Agree an individualised HbA1c target with each adult with type 1 diabetes, taking into account factors such as the person's daily activities, aspirations, likelihood of complications, comorbidities, occupation and history of hypoglycaemia. [new 2015] Support adults with type 1 diabetes to test at least four times a day, and up to 10 times a day if any of the following apply: desired target for blood glucose control, measured by HbA1c level, is not achieved frequency of hypoglycaemic episodes increases legal requirement to do so (such as before driving, in line with the Driver and Vehicle Licensing Agency (DVLA) during periods of illness before, during and after sport when planning pregnancy, during pregnancy and while breastfeeding (see the NICE guideline on diabetes in pregnancy) if there is a need to know blood glucose levels more than four times a day for other reasons (for example, impaired awareness of hypoglycaemia, high‑risk activities). [new 2015] Advise adults with type 1 diabetes to aim for: fasting plasma glucose level of 5–7 mmol/litre on waking plasma glucose level of 4–7 mmol/litre before meals at other times of the day. [new 2015] Insulin therapy Offer multiple da Continue reading >>

Diagnostic Criteria And Classification Of Dka

Diagnostic Criteria And Classification Of Dka

diagnostic criteria The diagnostic criteria for diabetic ketoacidosis are: ketonaemia 3 mmol /l and over or significant ketonuria (more than 2 + on standard urine sticks) blood glucose over 11 mmol /l or known diabetes mellitus venous bicarbonate (HCO3 ) ) below 15 mmol /l and /or venous pH less than 7.3 (1) The American Diabetes Association diagnostic criteria for DKA are as follows: elevated serum glucose level (greater than 250 mg per dL [13.88 mmol per L]) an elevated serum ketone level a pH less than 7.3 and a serum bicarbonate level less than 18 mEq per L (18 mmol per L) (2) classification of diabetic ketoacidosis DKA can be classified according to the severity into mild, moderate and severe (2) criterion mild (serum glucose > 250 mg/dL [13.88 mmol/L]) moderate (serum glucose > 250 mg/dL) severe (serum glucose > 250 mg/dL) anion gap > 10 mEq/L (10 mmol/L) > 12 mEq/L (12 mmol/L) > 12 mEq/L (12 mmol/L) arterial pH 7.24 to 7.30 7.00 to < 7.24 < 7.00 effective serum osmolality variable variable variable mental status alert alert/drowsy stupor/coma serum bicarbonate 15 to 18 mEq/L (15 to 18 mmol/L) 10 to < 15 mEq/L (10 to < 15 mmol/L) < 10 mEq/L (10 mmol/L) serum ketone positive positive positive urine ketone positive positive positive Reference: Continue reading >>

Joint British Diabetes Societies Hyperosmolar Hyperglycaemic State Guidelines Group3

Joint British Diabetes Societies Hyperosmolar Hyperglycaemic State Guidelines Group3

CURRENT TOPICS The management of the hyperosmolar hyperglycaemic state in adults with diabetes: a summary of a report from the Joint British Diabetes Societies for Inpatient Care AR SCOTT1 ON BEHALF OF THE JOINT BRITISH DIABETES SOCIETIES FOR INPATIENT CARE2 AND THE Abstract The Joint British Diabetes Societies for Inpatient Care have recently provided guidance on the management of hyper- osmolar hyperglycaemic state (HHS), a medical emergency which differs from diabetic ketoacidosis (DKA) through higher mortality and potential for complication by my- ocardial infarction, stroke, seizures, cerebral oedema and central pontine myelinolysis (the latter possibly precipi- tated by rapid changes in osmolality during treatment). DKA presents within hours of onset, whereas HHS devel- ops over many days, and its associated dehydration and metabolic disturbances are more extreme. A different therapeutic approach is required for HHS than for DKA. The key points in these guidelines are: Monitoring of the response to treatment: • Measure or calculate serum osmolality regularly to monitor the response to treatment • Aim to reduce osmolality by 3–8 mOsm/kg/h Fluid and insulin administration: • Use intravenous 0.9% sodium chloride solution as the principal fluid to restore circulating volume and reverse dehydration • Note that fluid replacement alone will cause a fall in blood glucose; withhold insulin until blood glucose is no longer falling with intravenous fluids alone (unless ketonaemic) • An initial rise in sodium is expected and is not itself an indication for hypotonic fluids • Early use of insulin (before fluids) may be detrimental Delivery of care: • Involve the diabetes specialist team as soon as possible. • Nurse patient Continue reading >>

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