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Dka Protocol Adults

Developments In The Management Of Diabetic Ketoacidosis In Adults: Implications For Anaesthetists

Developments In The Management Of Diabetic Ketoacidosis In Adults: Implications For Anaesthetists

Diabetic ketoacidosis (DKA) is a medical emergency and bedside capillary ketone testing allows timely diagnosis and identification of successful treatment. 0.9% saline with premixed potassium chloride should be the main resuscitation fluid on the general wards and in theatre; this is because it complies with National Patient Safety Agency recommendations on the administration of potassium chloride. Weight-based fixed rate i.v. insulin infusion (FRIII) is now recommended rather than a variable rate i.v. insulin infusion (VRIII). The blood glucose must be kept above 14 mmol litre−1 with the FRIII. Precipitating factor(s) needs to be identified and treated. Surgery and also critical care may be indicated to manage the patient presenting with DKA. Diabetic ketoacidosis (DKA) is a medical emergency. The diagnostic triad is: DKA can occur in both type 1 and type 2 diabetes mellitus and, although preventable, it remains a frequent and life-threatening complication. Errors in the management of DKA are not uncommon and are associated with significant morbidity and mortality. The majority of mortality and morbidity in DKA are attributable to delays in presentation and initiation of treatment. Rapid recognition and treatment of DKA is critical. Ketonaemia ≥3.0 mmol litre−1 or significant ketonuria (more than 2+ on urine sticks) Blood glucose >11.0 mmol litre−1 or known diabetes mellitus Bicarbonate <15.0 mmol litre−1, venous pH <7.3, or both. To overcome these concerns and to highlight current management strategies, the Joint British Diabetes Societies (JBDS) published guidelines in 2010. This was updated in consultation with the Intensive Care Society in September 2013.1 This article will review the pathophysiology of DKA and highlight the modern management of DKA that Continue reading >>

Diabetic Ketoacidosis In Adults

Diabetic Ketoacidosis In Adults

Pathophysiology Relative insulin deficiency = ↑Glu, ↓pH and ketonaemia. ↑glucagon, cortisol, catecholamines⇒ ↑ gluconeogenesis ⇒ ↑↑ glucose. ↑ lipolysis ⇒ ↑ FFA - ketogenesis - metab acidosis (3-β-hydroxybutyrate). Dehydration 2°: osmotic diuresis & vomiting = electrolyte (K+⇑ or K+⇓) shifts. Mortality from Children: Cerebral oedema Adults: ⇓K+, ARDS, co-existing sepsis/ AMI etc Aims and principles 1. Replace lost fluid & electrolytes 2. Correction of ketoacidosis Insulin suppression of ketogenesis Insulin stimulated entry of glucose into cells (correct ketonaemia) To achieve this you need to give enough insulin to correct the acidosis. Once the blood glucose falls you will often need to support the insulin with infused dextrose 3. Slow correct hyperglycaemia aim for glucose fall 3-5 mmol/l/hr only allow acidosis to correct as above No bicarb. unless pH < 6.9 If necessary use IL 1.26% solution + 20 mmol KCl 4. Treat cause Resuscitate A, B, C 1L over 1hr 1L over 2hr 1L over 4hr 1L over 8hr When Glu. <12mmol/L change to 5% dextrose When Glu. >12mmol/L change to normal saline If hypoglycaemia consider 10% dextrose Start infusion at 0.1U/Kg/hour Later move to sliding IV infusion rate Cap Glu. (mmol/L) Units / hr (=ml / hr) 0 - 4 0 4.1 - 6 0.5 6.1 - 8 1 8.1 - 10 2 10.1 - 12 3 12.1 - 16 4 16.1 - 20 6 > 20 Call doctor For patients on basal bolus insulin (e.g. Glargine, Detemir) it should be continued where possible. Additional Mx Monitor intake/output Hourly glucose monitoring. Aim for drop 4-5mmol/L/hr. Avoid rapid reduction. Check ketones every 1-2 hour Check K+ every 2-4 hrs (need ECG monitor?) Inform endocrine team of patient Do not use bicarbonate without prior discussion with EM senior/endocrine agreement Common DKA precipitants include infe Continue reading >>

Safety And Outcomes Of A “two-bag” Protocol For Management Of Dka In Adults By Nathan Haas

Safety And Outcomes Of A “two-bag” Protocol For Management Of Dka In Adults By Nathan Haas

Safety and Outcomes of a “Two-Bag” Protocol for Management of DKA in Adults by Nathan Haas 1. Safety and Outcomes of a “Two- Bag” Protocol for Management of DKA in Adults Nathan Haas MD, Kyle Gunnerson MD, Arun Ganti MD, Caryn Boyd BS, James A Cranford PhD, Sarah Hauser BSN, Christopher Hapner DO, Sage Whitmore MD 2. Background Kitabchi 2009 3. Background 4. Background Insulin ½ NS 20 KCl D10 ½ NS 20 KCl Off 250ml/hr 0.1 u/kg/hr Insulin ½ NS 20 KCl D10 ½ NS 20 KCl 125ml/hr 125ml/hr 0.1 u/kg/hr Insulin ½ NS 20 KCl D10 ½ NS 20 KCl 250mL/hrOff 0.1 u/kg/hr If BG > 250 mg/dL If BG 150-250mg/dL If BG < 150 mg/dL 5. One-Bag System Two-Bag System Insulin 0.9 NS KCl Hypoglycemia 0.9NS KCl D10 0.9NS KCl Insulin Insulin D10 0.9NS KCl Insulin ½ NS KCl D10 ½ NS KCl 0%100% Hypoglycemia Insulin ½ NS KCl D10 ½ NS KCl 50%50% Background 6. Background Grimberg et al. J Peds 1999 Pediatric Patients: • Faster response time in IV fluid therapy changes • Faster bicarbonate, ketone, and pH correction • More cost-effective care While 80% of cases of DKA occur in adults ages 18-65, neither the safety nor efficacy of the Two-Bag method have previously been studied in adult populations 7. Methods • A Two-Bag DKA protocol was operationalized in our adult ED in 2015 • Prior to this, our institutional DKA protocol involved a titratable insulin infusion and one IV fluid bag at a time of varying dextrose concentrations • A retrospective electronic medical record search identified adult ED patients presenting with ED diagnosis of DKA from January 1, 2013 to June 30, 2016 • Excluded if initial pH ≥ 7.30, HCO3 ≥ 18, anion gap ≤14, or blood glucose ≤ 200 • Excluded if neither order set was used, or if both order sets were used • Clinical and laboratory data, timi 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 >>

Diabetic Ketoacidosis And Hyperosmolar Hyperglycemic State In Adults: Treatment

Diabetic Ketoacidosis And Hyperosmolar Hyperglycemic State In Adults: Treatment

INTRODUCTION 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. They are part of the spectrum of hyperglycemia, and each represents an extreme in the spectrum. The treatment of DKA and HHS in adults will be reviewed here. The epidemiology, pathogenesis, clinical features, evaluation, and diagnosis of these disorders are discussed separately. DKA in children is also reviewed separately. (See "Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Epidemiology and pathogenesis".) (See "Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Clinical features, evaluation, and diagnosis".) 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 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 >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Print Overview Diabetic ketoacidosis is a serious complication of diabetes that occurs when your body produces high levels of blood acids called ketones. The condition develops when your body can't produce enough insulin. Insulin normally plays a key role in helping sugar (glucose) — a major source of energy for your muscles and other tissues — enter your cells. Without enough insulin, your body begins to break down fat as fuel. This process produces a buildup of acids in the bloodstream called ketones, eventually leading to diabetic ketoacidosis if untreated. If you have diabetes or you're at risk of diabetes, learn the warning signs of diabetic ketoacidosis — and know when to seek emergency care. Symptoms Diabetic ketoacidosis signs and symptoms often develop quickly, sometimes within 24 hours. For some, these signs and symptoms may be the first indication of having diabetes. You may notice: Excessive thirst Frequent urination Nausea and vomiting Abdominal pain Weakness or fatigue Shortness of breath Fruity-scented breath Confusion More-specific signs of diabetic ketoacidosis — which can be detected through home blood and urine testing kits — include: High blood sugar level (hyperglycemia) High ketone levels in your urine When to see a doctor If you feel ill or stressed or you've had a recent illness or injury, check your blood sugar level often. You might also try an over-the-counter urine ketones testing kit. Contact your doctor immediately if: You're vomiting and unable to tolerate food or liquid Your blood sugar level is higher than your target range and doesn't respond to home treatment Your urine ketone level is moderate or high Seek emergency care if: Your blood sugar level is consistently higher than 300 milligrams per deciliter (mg/dL), or 16.7 mill Continue reading >>

How To Identify And Manage Diabetic Ketoacidosis In Adults

How To Identify And Manage Diabetic Ketoacidosis In Adults

By Natasha Jacques, BSc, MRPharmS, and Sally James, MSc, MRPharmS In short Diabetic ketoacidosis (DKA) is a condition in which a lack of insulin leads to hyperglycaemia, ketosis and metabolic acidosis. The symptoms of DKA include thirst, polyuria, confusion, fatigue and nausea. Treatment of DKA centres around the administration of intravenous fluids (including potassium) and infusions of soluble insulin. Natasha Jacques is principal pharmacist for diabetes at Heart of England NHS Foundation Trust and Sally James is divisional pharmacist for medicine at Royal Liverpool and Broadgreen University Hospital NHS Trust. Both authors are committee members of the United Kingdom Clinical Pharmacy Association diabetes group. Call for Practice tools Useful clinical skills are described in this Clinical Pharmacist series. Comments on this or other articles are welcomed in the form of personal feedback to the editor or correspondence to Clinical Pharmacist. Pharmacists who have ideas for the series or wish to write an article are invited to contact the editor. Email: [email protected] Telephone: +44 (0)20 7572 2425 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 >>

Diabetic Ketoacidosis: Evaluation And Treatment

Diabetic Ketoacidosis: Evaluation And Treatment

Diabetic ketoacidosis is characterized by a serum glucose level greater than 250 mg per dL, a pH less than 7.3, a serum bicarbonate level less than 18 mEq per L, an elevated serum ketone level, and dehydration. Insulin deficiency is the main precipitating factor. Diabetic ketoacidosis can occur in persons of all ages, with 14 percent of cases occurring in persons older than 70 years, 23 percent in persons 51 to 70 years of age, 27 percent in persons 30 to 50 years of age, and 36 percent in persons younger than 30 years. The case fatality rate is 1 to 5 percent. About one-third of all cases are in persons without a history of diabetes mellitus. Common symptoms include polyuria with polydipsia (98 percent), weight loss (81 percent), fatigue (62 percent), dyspnea (57 percent), vomiting (46 percent), preceding febrile illness (40 percent), abdominal pain (32 percent), and polyphagia (23 percent). Measurement of A1C, blood urea nitrogen, creatinine, serum glucose, electrolytes, pH, and serum ketones; complete blood count; urinalysis; electrocardiography; and calculation of anion gap and osmolar gap can differentiate diabetic ketoacidosis from hyperosmolar hyperglycemic state, gastroenteritis, starvation ketosis, and other metabolic syndromes, and can assist in diagnosing comorbid conditions. Appropriate treatment includes administering intravenous fluids and insulin, and monitoring glucose and electrolyte levels. Cerebral edema is a rare but severe complication that occurs predominantly in children. Physicians should recognize the signs of diabetic ketoacidosis for prompt diagnosis, and identify early symptoms to prevent it. Patient education should include information on how to adjust insulin during times of illness and how to monitor glucose and ketone levels, as well as i Continue reading >>

454: Safety And Outcomes Of A Two-bag System For Management Of Dka In Adults

454: Safety And Outcomes Of A Two-bag System For Management Of Dka In Adults

Haas, Nathan; Gunnerson, Kyle; Ganti, Arun; Boyd, Caryn; Cranford, James; Hauser, Sarah; Hapner, Christopher; Whitmore, Sage Continue reading >>

My Site - Chapter 15: Hyperglycemic Emergencies In Adults

My Site - Chapter 15: Hyperglycemic Emergencies In Adults

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) should be suspected in ill patients with diabetes. If either DKA or HHS is diagnosed, precipitating factors must be sought and treated. DKA and HHS are medical emergencies that require treatment and monitoring for multiple metabolic abnormalities and vigilance for complications. A normal blood glucose does not rule out DKA in pregnancy. Ketoacidosis requires insulin administration (0.1 U/kg/h) for resolution; bicarbonate therapy should be considered only for extreme acidosis (pH7.0). Note to readers: Although the diagnosis and treatment of diabetic ketoacidosis (DKA) in adults and in children share general principles, there are significant differences in their application, largely related to the increased risk of life-threatening cerebral edema with DKA in children and adolescents. The specific issues related to treatment of DKA in children and adolescents are addressed in the Type 1 Diabetes in Children and Adolescents chapter, p. S153. Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are diabetes emergencies with overlapping features. With insulin deficiency, hyperglycemia causes urinary losses of water and electrolytes (sodium, potassium, chloride) and the resultant extracellular fluid volume (ECFV) depletion. Potassium is shifted out of cells, and ketoacidosis occurs as a result of elevated glucagon levels and absolute insulin deficiency (in the case of type 1 diabetes) or high catecholamine levels suppressing insulin release (in the case of type 2 diabetes). In DKA, ketoacidosis is prominent, while in HHS, the main features are ECFV depletion and hyperosmolarity. Risk factors for DKA include new diagnosis of diabetes mellitus, insulin omission, infection, myocardial infarc Continue reading >>

Diabetic Emergencies: Diabetic Ketoacidosis In Adults, Part 4

Diabetic Emergencies: Diabetic Ketoacidosis In Adults, Part 4

Treatment of Acidosis Most experts do not recommend the administration of bicarbonate because acidosis is corrected with insulin infusion and rehydration. The administration of bicarbonate in severe acidosis (pH less than 7.0) remains controversial.8 Severe metabolic acidosis exerts a negative inotropic effect on the heart, induces vasodilation and hypotension, reduces glucose uptake and utilization, and promotes ventricular arrhythmias.6 On the other hand, bicarbonate therapy may lead to worsening of hypokalemia (especially at the beginning of bicarbonate administration), intracellular acidosis in the central nervous system (paradoxical acidosis),27 and metabolic alkalosis.6 One study showed that bicarbonate administration had no benefits for patients with DKA and initial pH 6.9-7.15.28 However, in this trial the number of patients with pH in this range was very small. Based on existing evidence and expert opinion, it may be prudent to administer 50 mmol of bicarbonate in 200 ml water with 10 mEq of potassium chloride over 1 hour in patients whose pH is 6.9-7.0 or serum bicarbonate less than 5 mEq/L. In patients with pH less than 6.9, doubling of the above bicarbonate dose is recommended. Arterial pH should be monitored 2 hours later and the dose should be repeated if pH remains lower than 7.0.8,10 Electrolyte replacement Replacement of sodium and chloride deficits is achieved by the administration of normal saline as described above. Particular attention should be paid to potassium restoration. As mentioned, serum potassium concentrations are usually normal or increased despite the significant total body deficit. During treatment of DKA potassium levels are decreased, sometimes very quickly, because correction of acidosis and the insulin infusion move potassium into t 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 >>

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