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 >>
Diabetic Ketoacidosis In Children And Adolescents Raghupathy P - Indian J Endocr Metab
Diabetic ketoacidosis (DKA) is considered to be a common presentation of type 1 diabetes mellitus (T1DM) and occasionally, type 2 diabetes mellitus (T2DM) in children and adolescents. DKA arises due to lack of adequate insulin in the body. Insulin stops the use of fat as an energy source by inhibiting the peptide hormone glucagon. Without insulin, glucagon levels rise resulting in the release of free fatty acids from adipose tissue, as well as amino acids from muscle cells. The biochemical criteria for DKA diagnosis include hyperglycemia (blood glucose [BG] higher than 11 mmol/L or 200 mg/dL) with a venous pH of <7.3 and/or a bicarbonate (HCO 3 ) level of <15 mmol/L; ketonemia and ketonuria. Although not universally available, blood -hydroxybutyrate concentration should be measured whenever possible, and a level of 3 mmol/L is indicative of DKA. Urine ketones, of moderate or large size (typically 2+), are also indicative of DKA. The clinical signs of DKA include dehydration (may be difficult to detect), tachycardia, tachypnoea (may be mistaken for pneumonia or asthma), deep sighing (Kussmaul) respiration with a typical smell of ketones in the breath (variously described as the odor of nail polish remover or rotten fruit), nausea, vomiting (may be mistaken for gastroenteritis), abdominal pain (may mimic an acute abdominal condition), confusion, drowsiness, progressive reduction in level of consciousness, and eventually loss of consciousness. Risk factors for DKA in newly diagnosed cases include younger age (<2 years), delayed diagnosis, and lower socioeconomic status with limited access to medical services. Risk factors for DKA in patients with known diabetes include insulin omission, poor metabolic control, previous episodes of DKA, acute gastroenteritis with persisten Continue reading >>
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 >>
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 >>
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 >>
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 (DKA) is a metabolic emergency occurring in Type 1 diabetes. It is characterised by the following: Acidosis: Blood pH below 7.3 or plasma bicarbonate below 18mmol/litre Ketonaemia: Blood ketones (beta-hydroxybutyrate) above 3mmol/litre Hyperglycaemia: Blood glucose levels are generally high (above 11mmol/litre), although children with known Type 1 diabetes can less commonly develop DKA with normal blood glucose levels DKA can be life threatening. The three complications which account for the majority of deaths in these children are cerebral oedema, hypokalaemia and aspiration pneumonia. An understanding of the principles discussed in the ‘Approach to the Seriously Unwell Child’ article and an awareness of the British Society of Paediatric Endocrinology and Diabetes (BSPED) guideline for DKA management (1) will help you manage these children appropriately. 31,500 children and young people under the age of 19 in the UK have diabetes. The vast majority of them (over 95%), have Type 1 Diabetes Mellitus (T1DM.) The peak age for diagnosis is between 9 and 14 years (2). In established T1DM, the risk of DKA is 1–10% per patient per year (3). Reported mortality rates from DKA in children in the UK are around 0.3%, the majority of which are attributable to cerebral oedema, which has a mortality rate of 25 % (4). T1DM can be seen as ‘starvation in the midst of plenty,’ where blood glucose levels are raised as it cannot be used for metabolism or stored due to an absolute deficiency of insulin. This leads to a rise in counter-regulatory hormones including glucagon, cortisol, catecholamines and growth hormone. The increase in these gluconeogenic hormones not only raises the blood glucose concentration further, but also leads to accelerated break down o Continue reading >>
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
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 >>
Management Of Paediatric Diabetic Ketoacidosis: An Audit
Introduction: NICE Guidelines NG18 (published 2015) advocate a more conservative approach to management of diabetic ketoacidosis (DKA) in children and young people up to the age of 18, in an attempt to reduce the risk of cerebral oedema. We aimed to assess if management of DKA in children at Manor Hospital was compliant with hospital guidelines, that were based on BSPED guidelines (issued 2009). We analysed the difference in total fluid administered if the new DKA guidelines were in place, specifically in the case of young people. Method: We retrospectively audited case notes of all patients up to the age of 19 years admitted to Walsall Manor Hospital with DKA between 1st July 2014–31st July 2015 (n=13). A standardised proforma was used to collect data, which was then analysed. Results: Current hospital policy advocates that young people after their 16th birthday are managed by the adult medical team. The adult DKA Guideline is based on recommendations of Joint British Diabetes Societies Inpatient Care Group recommendations (2013). The age range was 10 to 18 years. Ten patients were treated using the paediatric and three were treated using the adult guidelines. There was one significant fluid calculation error found in a patient treated with the paediatric guidelines, although the patient did not come to any harm. No fluid calculation error was found in those patients treated with adult guidelines, though one patient developed fluid overload not requiring active treatment. Mathematical modelling of fluid given in the first 12 hours of treatment shows that a young person would receive 40–70% less fluids if treated as per NICE NG18 instead of adult DKA Guidelines. In terms of other complications, there were 12 episodes of hypoglycaemia, but no episodes of hypokalaemia Continue reading >>
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 >>
1. Start Iv Fluids (1 L Of 0.9% Nacl Per Hr Initially) 2. If Serum K+ Is <3.3 Meq/l Hold Insulin
DKA Diagnostic Criteria (See page 3 for more details):  Blood glucose >250 mg/dl,  Arterial pH <7.3,  Bicarbonate ≤18 mEq/l,  Anion Gap Acidosis  Moderate ketonuria or ketonemia.  Give 40 mEq/h until K ≥ 3.3 mEq/L 3. Initiate DKA Order Set Phase I 4. Start insulin 0.14 units/kg/hr IV infusion (calculate dose) RN will titrate per DKA protocol Insulin Potassium Bicarbonate IVF Look for the Cause - Insulin deficiency - Infection/Inflammation (PNA, UTI, pancreatitis, cholecystitis) - Ischemia/Infarction (myocardial, cerebral, gut) - Intoxication (EtOH, drugs) - Iatrogenic (drugs, lack of insulin) - Pregnancy DKA/HHS Pathway Phase 1 (Adult) Approved by Diabetes Steering Committee, MMC, 2015 Initiate and continue insulin gtt until serum glucose reaches 250 mg/dl. RN will titrate per protocol to achieve target. When sugar < 250 mg/dl proceed to DKA Phase II (reverse side) DKA/HHS Pathway Phase 2 (Adult) Non-ICU Patients Phase 2: Blood sugar now less than 250mgd/dl. If Anion Gap Normalized* If Anion Gap Elevated* Critical Illness (ICU) Follow guidelines to the right when gap has normalized.* Approved by Glycemic Steering Committee, MMC, 2015  Transition to DKA Order Set Phase 2  Discontinue Phase 1 insulin infusion order and DKA nursing titration protocol from phase 1.  Change to fixed dose insulin infusion at suggested rate of 2.5 units/hr (Adjust as needed for individual patient with typical dose range of 0.02 to 0.05 units/kg/hr based on drip rate and response in phase 1). Do not discontinue insulin therapy.  Start dextrose containing IV fluid such as D5 ½ NS and adjust dextrose to goal blood sugar 150- 200.  Continue to check labs regularly.  Reevaluate for underlying causes a Continue reading >>
Diagnosis
Print If your doctor suspects diabetic ketoacidosis, he or she will do a physical exam and various blood tests. In some cases, additional tests may be needed to help determine what triggered the diabetic ketoacidosis. Blood tests Blood tests used in the diagnosis of diabetic ketoacidosis will measure: Blood sugar level. If there isn't enough insulin in your body to allow sugar to enter your cells, your blood sugar level will rise (hyperglycemia). As your body breaks down fat and protein for energy, your blood sugar level will continue to rise. Ketone level. When your body breaks down fat and protein for energy, acids known as ketones enter your bloodstream. Blood acidity. If you have excess ketones in your blood, your blood will become acidic (acidosis). This can alter the normal function of organs throughout your body. Additional tests Your doctor may order tests to identify underlying health problems that might have contributed to diabetic ketoacidosis and to check for complications. Tests might include: Blood electrolyte tests Urinalysis Chest X-ray A recording of the electrical activity of the heart (electrocardiogram) Treatment If you're diagnosed with diabetic ketoacidosis, you might be treated in the emergency room or admitted to the hospital. Treatment usually involves: Fluid replacement. You'll receive fluids — either by mouth or through a vein (intravenously) — until you're rehydrated. The fluids will replace those you've lost through excessive urination, as well as help dilute the excess sugar in your blood. Electrolyte replacement. Electrolytes are minerals in your blood that carry an electric charge, such as sodium, potassium and chloride. The absence of insulin can lower the level of several electrolytes in your blood. You'll receive electrolytes throu Continue reading >>
Learning From Practice
Management of diabetic ketoacidosis following implementation of the JBDS guidelines: Where are we and where should we go? WINSTON CRASTO,1 ZIN ZIN HTIKE,2 LISA TURNER,3 KATH HIGGINS4 Abstract Background: The Joint British Diabetes Society (JBDS) consensus guideline published in 2010 has provided the framework for the effective management of diabetic ketoacidosis (DKA) in adults in the UK. Methodology: A retrospective study of 50 patient episodes admitted to our teaching hospital between February and December 2012, with a discharge diagnosis of DKA. Results: Twenty-seven (54%) patients were male, mean (SD) age was 43 (21) years and duration of diabetes was 11 (9) years. In the first 60 minutes from diagnosis, median (interquartile range [IQR]) time to fixed rate intravenous insulin infusion (FRIII) was 49 (29–110) minutes and to in- travenous fluids was 19 (0–42) minutes. During ongoing management, 46% of patients developed hypokalaemia and, of those, in 70% potassium supplementation was not prescribed as per protocol. Forty percent of patients expe- rienced hypoglycaemia in the first 24 hours, of whom 80% had 10% dextrose prescribed appropriately according to protocol. Median time to hypoglycaemia from diagnosis was 12 hours 54 minutes. Median (SD) time to resolution of DKA was 12 hours 6 minutes. Eighty six percent of patients were reviewed by the diabetes specialist team during admission. No deaths due to DKA or complications of its management were reported. Median length of hos- pital stay was two days. Conclusions: Adherence to the JBDS DKA guideline was good in the immediate stage of treatment. Inadequate metabolic monitoring, fluid management and iatrogenic hypoglycaemia remain areas of concern. A high propor- tion of patients received diabetes speci Continue reading >>
Treatment Of Diabetic Ketoacidosis (dka)/hyperglycemic Hyperosmolar State (hhs): Novel Advances In The Management Of Hyperglycemic Crises (uk Versus Usa)
Go to: Diabetic Ketoacidosis Prior to the discovery and isolation of insulin in 1922 by Banting and Best, type 1 diabetes was universally fatal within a few months of initial diagnosis. Once mass production was started, the challenge to those early pioneers of insulin treatment was learning how to use this new wonder drug, e.g., how much to give and how often to give it, in order to treat the hyperglycemia without raising the inherent risk of hypoglycemia. In 1945, Howard Root in Boston described how they had improved the outcomes for people with diabetic ketoacidosis (DKA), reducing mortality to 12% by 1940 and to 1.6% by 1945 using high doses of insulin—giving an average of 83 units within the first 3 h of treatment in 1940 and 216 units by 1945 [3]. They described how in 1945, they used an average of 287 units in the first 24 h, but this ranged from 50 to 1770 units [3]. In Birmingham, UK, high-dose insulin was also being used with similar success—doses varying depending on the degree of consciousness, with those unarousable on admission given doses between 500 and 1400 units per 24 h [4]. DKA remains a medical emergency; over time, mortality has continued to fall but remains a significant risk, especially amongst the young, socially isolated and when care provision is fragmented [5•, 6•]. Overall, the diagnosis and treatment of DKA are very similar in the UK and USA with a few differences. The UK has separate guidelines on the management of DKA [7], while the USA has a position statement on DKA and HHS that was updated in 2009 [8]. The UK guideline differs in several ways from the US position statement. The concept of low-dose intravenous insulin was established in the late 1960s and early 1970s by teams on both sides of the Atlantic. The UK championed the u Continue reading >>
