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Dka Guidelines

C6.2.1.diabetic Keto Acidosis (dka)

C6.2.1.diabetic Keto Acidosis (dka)

DKA is a potentially life threatening complication of diabetes that while often preventable, must be dealt with as a matter of urgency once established. Diagnosis of DKA is only appropriate in the presence of diabetes AND ketosis AND acidosis. A national protocol for management of confirmed DKA in adults only is being rolled out in summer 2011; it can also be down loaded from the link below. A separate paediatric protocol is available for children under the age of 16 years. The paediatric protocol may also be appropriate in adults of low body weight (BMI < 16kg/m2), as it reduces the risk of fluid overload. The Diabetes specialist team should be contacted as appropriate for advice regarding management of DKA Consideration must be given to the cause of DKA for example, infection, myocardial infarction or insulin administration difficulties and the underlying cause appropriately treated. The Diabetes specialist team should be contacted as appropriate for advice regarding management of DKA and, once the patient is stable, for education to try to prevent recurrence. Continue reading >>

Diabetic Ketoacidosis (dka) Guidelines

Diabetic Ketoacidosis (dka) Guidelines

Adult Diabetic Ketoacidosis (DKA) Guidelines and Management Record …. 2015 FSH version pending approval and implementation Date implemented – 02/2008 Review date – currently being revised Author – Joey Kaye (Endocrinology Department), Michael Baker Yes, add me to your mailing list. Continue reading >>

Pediatric Diabetic Ketoacidosis – Guideline From Royal Children’s Hospital Melbourne

Pediatric Diabetic Ketoacidosis – Guideline From Royal Children’s Hospital Melbourne

Our goal as primary care physicians is to make the diagnosis of Type 1 Diabetes or Diabetic Ketoacidosis at the earliest opportunity and then immediately arrange for inpatient expert follow up at a tertiary care center. Twenty-five percent of patients with a new diagnosis of diabetes present with diabetic ketoacidosis; a missed diagnosis of diabetes is the most common cause, especially in young children. [from Pediatric Diabetic Ketoacidosis Emergency Department Care of emedicine.medscape.com] What follows are excerpts of Pediatric Type 1 Diabetes Mellitus Clinical Presentation Updated: Apr 27, 2017 from emedicine.medscape.com: Symptoms of ketoacidosis These symptoms include the following: What follows are only excerpts from the Diabetes Mellitus Guideline. Please see the complete protocol] on diabetic ketoacidosis from the Royal Children’s Hospital Melbourne: 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 [200 mg/dl] 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‘ bel Continue reading >>

Management Of Diabetic Ketoacidosis In Adults

Management Of Diabetic Ketoacidosis In Adults

Diabetic ketoacidosis is a potentially life-threatening complication of diabetes, making it a medical emergency. Nurses need to know how to identify and manage it and how to maintain electrolyte balance Continue reading >>

Hyperglycemic Crises In Diabetes

Hyperglycemic Crises In Diabetes

Ketoacidosis and hyperosmolar hyperglycemia are the two most serious acute metabolic complications of diabetes, even if managed properly. These disorders can occur in both type 1 and type 2 diabetes. The mortality rate in patients with diabetic ketoacidosis (DKA) is <5% in experienced centers, whereas the mortality rate of patients with hyperosmolar hyperglycemic state (HHS) still remains high at ∼15%. The prognosis of both conditions is substantially worsened at the extremes of age and in the presence of coma and hypotension (1–10). This position statement will outline precipitating factors and recommendations for the diagnosis, treatment, and prevention of DKA and HHS. It is based on a previous technical review (11), which should be consulted for further information. PATHOGENESIS Although the pathogenesis of DKA is better understood than that of HHS, the basic underlying mechanism for both disorders is a reduction in the net effective action of circulating insulin coupled with a concomitant elevation of counterregulatory hormones, such as glucagon, catecholamines, cortisol, and growth hormone. These hormonal alterations in DKA and HHS lead to increased hepatic and renal glucose production and impaired glucose utilization in peripheral tissues, which result in hyperglycemia and parallel changes in osmolality of the extracellular space (12,13). The combination of insulin deficiency and increased counterregulatory hormones in DKA also leads to the release of free fatty acids into the circulation from adipose tissue (lipolysis) and to unrestrained hepatic fatty acid oxidation to ketone bodies (β-hydroxybutyrate [β-OHB] and acetoacetate), with resulting ketonemia and metabolic acidosis. On the other hand, HHS may be caused by plasma insulin concentrations that are in Continue reading >>

Management Of Diabetic Ketoacidosis (dka)

Management Of Diabetic Ketoacidosis (dka)

Management of Acute Diabetic Ketoacidosis (DKA) Below is the link to the care pathway for the management of diabetic ketoacidosis in adults. Specific guidelines exist for the management of DKA in children. In patients aged 13-16 years presenting with DKA, the management of DKA should be discussed with relevant paediatric staff. Diagnosis Severe uncontrolled diabetes with: Hyperglycaemia (blood glucose >14mmol/L, usually but not exclusively) Metabolic acidosis (H+ >45mEq/L or HCO3- <18mmol/L or pH <7.3 on venous gases) Ketonaemia (>3mmol/L) / ketonuria (>++) Severity criteria One or more of the following may indicate severe DKA and should be considered for level 2 care (MHDU if available). It may also be necessary to consider a surgical cause for the deterioration. Blood ketones >6mmol/L Bicarbonate level <5mmol/L Venous / artierial pH <7.1 Hypokalaemia on admission (<3.5mmol/L) GCS <12 or abnormal AVPU scale Oxygen saturation <92% on air (assuming normal baseline respiratory function) Systolic BP <90mmHg, pulse >100bpm or <60bpm Anion gap >16 [anion gap = (Na+ + K+) – (Cl- + HCO3-)] Cerebral oedema The care pathways for the emergency management of DKA should be used for all eligible patients. Complete pathways for 0–4 hours and 4 hours–discharge for each DKA episode. These provide instruction on fluid balance, insulin and potassium replacement. Please note there are DKA order sets on TrakCare (DKA baseline and DKA continuing care). The care pathways are available within relevant departments or online at NHSGGC Managed Clinical Networks / Diabetes MCN / Clinical Guidelines and Protocols / DKA Care Pathway. Supplementary notes as per care pathway 0–4 hours Continue background SC insulin (glargine, levemir, degludec, isophane insulin) while on fixed rate intravenou Continue reading >>

Diabetic Ketoacidosis: Clinical Practice Guidelines

Diabetic Ketoacidosis: Clinical Practice Guidelines

1. Introduction Diabetic ketoacidosis (DKA), the most common endocrinal emergency remains a life-threatening condition despite improvements in diabetes care [1]. The mortality and morbidity rates remain high worldwide, especially in developing countries and among non-hospitalized patients [2,3], which highlight the importance of early diagnosis and implementation of effective preventive and management strategies. The adage "The child is not a miniature adult" is most appropriate when considering DKA. The fundamental pathophysiology of DKA is the same in children as in adults; however, the child differs from the adult in a number of characteristics which raise some important considerations in management [2]. The purpose of this chapter is to briefly review the pathophysiology of DKA and discuss recommended treatment protocols and current standards of care pertaining to children, adolescents and adults with type 1 or 2 diabetes presenting with DKA. The information provided is based on evidence from published studies and internationally accepted guidelines whenever possible and, when not, supported by expert opinion or consensus [1-5]. Current concepts of cerebral edema, recommendations and strategies for the prediction and prevention of DKA and hence its complications are finally presented. The considerations and recommendations included are in agreement with those endorsed by the American Diabetes Association (ADA), Lawson Wilkins Pediatric Endocrine Society (LWPES), European Society for Pediatric Endocrinology (ESPE), and the International Society for Pediatric and Adolescent Diabetes (ISPAD) [2-5]. Thus, this book chapter will provide easy and practical information to guide healthcare professional who manage DKA in all age groups. 2. Definition of Diabetic Ketoacidosis Continue reading >>

Diabetic Ketoacidosis Treatment & Management

Diabetic Ketoacidosis Treatment & Management

Approach Considerations Managing diabetic ketoacidosis (DKA) in an intensive care unit during the first 24-48 hours always is advisable. When treating patients with DKA, the following points must be considered and closely monitored: It is essential to maintain extreme vigilance for any concomitant process, such as infection, cerebrovascular accident, myocardial infarction, sepsis, or deep venous thrombosis. It is important to pay close attention to the correction of fluid and electrolyte loss during the first hour of treatment. This always should be followed by gradual correction of hyperglycemia and acidosis. Correction of fluid loss makes the clinical picture clearer and may be sufficient to correct acidosis. The presence of even mild signs of dehydration indicates that at least 3 L of fluid has already been lost. Patients usually are not discharged from the hospital unless they have been able to switch back to their daily insulin regimen without a recurrence of ketosis. When the condition is stable, pH exceeds 7.3, and bicarbonate is greater than 18 mEq/L, the patient is allowed to eat a meal preceded by a subcutaneous (SC) dose of regular insulin. Insulin infusion can be discontinued 30 minutes later. If the patient is still nauseated and cannot eat, dextrose infusion should be continued and regular or ultra–short-acting insulin should be administered SC every 4 hours, according to blood glucose level, while trying to maintain blood glucose values at 100-180 mg/dL. The 2011 JBDS guideline recommends the intravenous infusion of insulin at a weight-based fixed rate until ketosis has subsided. Should blood glucose fall below 14 mmol/L (250 mg/dL), 10% glucose should be added to allow for the continuation of fixed-rate insulin infusion. [19, 20] In established patient 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 >>

Will Diabetes Mellitus Be Curable In The Future? Is There Any Work For Applying A Treatment?

Will Diabetes Mellitus Be Curable In The Future? Is There Any Work For Applying A Treatment?

Cure?: A cure is the end of a medical condition; the substance or procedure that ends the medical condition, such as a medication, a surgical operation, a change in lifestyle, or even a philosophical mindset that helps end a person's sufferings; or the state of being healed, or cured. A remission is a temporary end to the medical signs and symptoms of an incurable disease. A disease is said to be incurable if there is always a chance of the patient relapsing, no matter how long the patient has been in remission. An incurable disease may or may not be a terminal illness; conversely, a curable illness can still result in the patient's death. Urgent diabetes Health Bulletin from the doctors at "The International Council for Truth in medicine" on Diabetes Facts You can't ignore!!! Approach Considerations: Patients with type 1 diabetes mellitus (DM) require lifelong insulin therapy. Most require 2 or more injections of insulin daily, with doses adjusted on the basis of self-monitoring of blood glucose levels. Long-term management requires a multidisciplinary approach that includes physicians, nurses, dietitians, and selected specialists. In some patients, the onset of type 1 DM is marked by an episode of diabetic ketoacidosis (DKA) but is followed by a symptom-free “honeymoon period” in which the symptoms remit and the patient requires little or no insulin. This remission is caused by a partial return of endogenous insulin secretion, and it may last for several weeks or months (sometimes for as long as 1-2 years). Ultimately, however, the disease recurs, and patients require insulin therapy. Often, the patient with new-onset type 1 DM who presents with mild manifestations and who is judged to be compliant can begin insulin therapy as an outpatient. However, this approach Continue reading >>

Clinical Management Of Diabetic Ketoacidosis

Clinical Management Of Diabetic Ketoacidosis

Abstract: Background: Diabetic ketoacidosis (DKA) is a medical emergency where rapid and effective management is necessary to aid prompt recovery and to prevent life threatening complications such as: cerebral oedema, hypokalaemia, hypo/hyper-glycaemia and hypovolaemia. It requires effective co-operation between the emergency department (ED), general medical team and endocrinology team members. Within the past 4 years, a new national guideline regarding the management of DKA has been used by the majority of hospitals in the United Kingdom (1). One of many points in these guidelines is that a fixed rate of iv insulin infusion with appropriate rate of iv fluids (normal saline and 10% of glucose) is preferable to variable insulin infusion. The new guidelines describe clearly each step of DKA management. This audit investigated the management of DKA at Medway Hospital to see if national and local hospital guidelines were being adhered to. Aims and Objectives: Multiple steps of clinical management of DKA were examined, including: recognition of DKA, initiation of treatment, the occurrence of hypoglycaemia and hypokalaemia, blood glucose and ketones monitoring, venous blood gases monitoring and referral to endocrinology team. Results were presented to medical and ED doctors during a hospital audit meeting. Methods: The search code in the hospital audit database was “diabetic ketoacidosis” and identified 34 cases between January and June 2014. The audit collection tool was a standard national DKA audit proforma. The national and local DKA guidelines were used as a standard. Results: Thirty four patients were treated for DKA. Only 82% of patients had treatment started within 1 hour of arrival in accordance with DKA guidelines. The major challenges identified were: Inadequat Continue reading >>

Diabetic Ketoacidosis (dka): Treatment Guidelines

Diabetic Ketoacidosis (dka): Treatment Guidelines

Diabetic ketoacidosis (DKA), resulting from severe insulin deficiency, accounts for most hospitalization and is the most common cause of death, mostly due to cerebral edema, in pediatric diabetes. This article provides guidelines on management to restore perfusion, stop ongoing ketogenesis, correct electrolyte losses, and avoid hypokalemia and hypoglycemia and the circumstances that may contribute, in some instances, to cerebral edema (overhydration, rapid osmolar shifts, hypoxia). These guidelines emphasize the importance of monitoring glycemia, electrolytes, hydration, vital signs, and neurologic status in a setting where response can be rapid if necessary (e.g., mannitol for cerebral edema). Most important is the prevention of DKA in established patients by close supervision of those most likely to omit insulin, or during illness, and a high index of suspicion for diabetes to prevent deterioration to DKA in new patients, particularly those under age 5, who are at greatest risk of complications. Continue reading >>

Management Of Diabetic Ketoacidosis: New Guidelines Published

Management Of Diabetic Ketoacidosis: New Guidelines Published

New guidelines for the management of adults with diabetic ketoacidosis (DKA) have been published by the Joint British Diabetes Societies Inpatient Care Group. The guidelines have been developed by a multidisciplinary group of practising specialists to reflect advances in near patient testing and changes in UK practice that have taken place in the past decade, the authors say. In the foreword, Gerry Rayman, NHS Diabetes clinical lead for inpatient diabetes care, recommends the guidelines to all diabetes hospital teams for rapid introduction and for acceptance as the national guideline for managing DKA. “Their widespread introduction should significantly improve the care of people admitted with DKA,” he says. Dr Rayman points out that errors in management of DKA are not uncommon and are associated with significant morbidity and mortality. He says that, although most acute hospitals have guidelines for the management of this condition, they are often out of date. Adherence to the guidelines also varies between admitting teams, he adds. The new guidelines cover: rationale for best practice; controversial areas; serious complications of DKA or its treatment; DKA pathway of care; and implementation and audit. Sally James, diabetes and divisional pharmacist for medicine, Royal Liverpool University Hospital, told PJ Online that she welcomes the introduction of national guidance on the treatment of DKA. “With national guidance it is hoped all trusts will make sure their policies are updated, easily accessible and, importantly, audited to check that they are adhered to. This will hopefully mean improvements in the treatment of patients that present with DKA since this condition is associated with mortality and morbidity if poorly managed,” said Miss James. She highlights 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 >>

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 >>

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