Jun 30, 2014 dka management protocols in clinical care. Most cases of dka can be prevented by using an effective diabetes management plan that includes patient selfcare. Diabetic ketoacidosis dka is an emergency for people with diabetes characterized by hyperglycemia, metabolic acidosis, and ketosis. 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. Management of diabetic ketoacidosis article pdf available in the indian journal of pediatrics 785. To address these issues the joint british diabetes societies jbds, supported by nhs diabetes, has produced this revision of the 2010 guidance developed by a multidisciplinary group of practicing specialists with considerable experience in this area. Dka is the leading cause of death in children with type 1 diabetes 1, 2 and accounts for a significant proportion of admissions in adult patients with type 1 or type 2 diabetes 1, 3.
Blood glucose bg 200 mgdl acidosis bicarbonate dka, and when patient is able to eat, initiate a multidose insulin regimen. Management of feline diabetic ketoacidosis wsava20 vin. Community resources and policies identifying or developing resources to support healthy lifestyles 6. Aug 01, 2019 diabetic ketoacidosis dka occurs when there is a relative or absolute decrease in circulating insulin levels in relation to an increase in counterregulatory hormone levels. Guidelines and position statements from medical the care of their patients. Diabetic ketoacidosis dka care guidelines emergency department management inclusion criteria definition of dka.
It has been benchmarked against joint british diabetes societies jbds guidance, to provide guidance on the clinical management of dka in line with best practice guidelines. Intravenous fluids are essential in management of dka. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. This is an important advance in the management of dka sheikhali 2008, bektas 2004. Management of diabetic ketoacidosis and hyperosmolar. Diabetic ketoacidosis dka management algorithm adult. Prebreakfast administer both glargine and aspart dose according to premeal aspart order set. Change in blood glucose trend insulin infusion titration. Diabetic ketoacidosis dka and the hyperosmolar hyperglycemic state hhs are the two most serious acute metabolic complications of diabetes. Diabetic ketoacidosis dka represents a profound insulindeficient state characterized by hyperglycemia 200 mgdl 11. Trusts need to ensure that they have local protocols in place, which allow for the. Sk226 0812 diabetic ketoacidosis management protocol. Dka at diagnosis is more common in children management of an episode of dka is not complete until an attempt has been made to identify and treat the cause. The time to resolution of dka, complications and deaths were recorded.
Dka guideline for diagnosis hhs guideline for diagnosis. This algorithm has been developed for md anderson using a multidisciplinary approach considering circumstances particular to md andersons. Weve helped produce the management of diabetic ketoacidosis in adults, pdf, 4mb published by the joint british diabetes societies inpatient car. Management of acute diabetic ketoacidosis dka below is the link to the care pathway for the management of diabetic ketoacidosis in adults. Diabetic ketoacidosis dka, a lifethreatening complication of type 1 diabetes, is preventable but errors in the way it is managed are common and and associated with significant morbidity and mortality. Practice guidelines resources american diabetes association. Guidelines for the management of patients with dka and hhs in. The 2009 american diabetes association ada position statement on hyperglycaemic emergencies in adult patients with diabetes details the management of diabetic ketoacidosis dkaand hyperosmolar. Development and implementation of a hyperglycemic emergency.
Dka without a preceding febrile illness or gastroenteritis in a patient with known diabetes is almost always the result of psychosocial problems and failure to appropriately administer insulin. Diabetic ketoacidosis dka is an acute metabolic complication of diabetes that is potentially fatal and requires prompt medical attention for successful treatment. One approach to delivering best clinical practices is development of inpatient standardized protocols for dka management. Diabetic ketoacidosis is a complication for some patients with insulindependent diabetes mellitus as well as for noninsulin dependent. Clinicians should understand the appropriate management and risks associated with treatment of children with diabetic ketoacidosis. In the last decade, however, there has been a change in the way patients with dka present clinically and in addition there has been rapid development of nearpatient testing. Management of diabetic ketoacidosis in adults clinical guideline v4.
In addition to rehydration, fluids will help lower plasma glucose by dilution and increasing glomerular filtration rate. The current management protocol at chbah was observed, i. These guidelines recommend that management is based on bedside monitoring of patients with dka. The management of dka requires a full complement of hospital, emergency, and intensive care services. Glycemic control of diabetes mellitus protocol stanford coordinated care page 1 purpose. Guidelines for management of diabetic ketoacidosis. Joint british diabetes societies guideline for the management of diabetic ketoacidosis.
The protocol for the management of patients with dka is presented in figure 1. Divisions of pediatric emergency medicine and endocrinology date of approval. If protocol contraindicated or not ordered, notify physician. Emergency department management clinical practice guideline cpg protocol approved by. Perhaps even more importantly, because dka is a multiday and therefore multidoctor management disease, the team of doctors who manage inpatients should become familiar with more than one protocol, and have a group decision about which protocol s you will use in your hospital. Dka onset and recurrence can largely be prevented through patient education. Hyperglycemic hyperosmolar state insulin titration iii.
Understand the basic clinical presentation, diagnostic tests, and management of dka. Recommendations concerning fluid management have been modified to reflect recent findings from a randomized controlled clinical trial showing no difference in cerebral injury in patients rehydrated at different rates with either 0. Guidelines and position statements from medical organisations are widely used by clinicians to guide the care of their patients. This article outlines updates in the clinical management of. Experienced nursing staff trained in monitoring and management of dka in children and adolescents. Place of management the child with dka should receive care in a unit that has. They are part of the spectrum of hyperglycemia, and each represents an extreme in the spectrum. Dka treatment protocol barbara davis center for childhood. Table 1 outlines the diagnostic criteria for dka and hhs. In the united states, more than 100,000 individuals are hospitalized each year for dka and the mortality rate is 2% to 5%. Specific guidelines exist for the management of dka in children.
Stanford hospital and clinics glycemic control of diabetes mellitus stanford coordinated care glycemic control of diabetes mellitus protocol stanford coordinated care page 1 purpose. Diabetic ketoacidosis dka critical care guideline two bag system inclusion criteria definition of dka. Management of diabetic ketoacidosis in adults queensland health. To enhance collaborative patient care by referral of patients with a diagnosis of type 1 or type2 diabetes dm to be comanaged by the clinical pharmacist, pharmacy resident or rn following this. Diabetic ketoacidosis carries a significant mortality rate and close monitoring is essential. Diabetic ketoacidosis dka critical care guideline two bag. Clinicians should use the protocol they are most comfortable using. Hyperglycemic crises in adult patients with diabetes. It is treated commonly in the intensive care unit icu, even though clinical data from many studies support management in regular medicalsurgical wards, avoiding expensive critical care unit costs and preventing bed crisis in these higher level. Diabetic ketoacidosis dka critical care guidelines continued transition to sq insulin guidelines for transition 1 ph 7.
Acute management of diabetic ketoacidosis in adults this protocol is for the acute management of diabetic ketoacidosis in patients 16 years and over. After completing this article, readers should be able to. Those with severe dka have a much higher mortality and risk of complications. Diabetic ketoacidosis american academy of pediatrics. Phase type of fluid rate iv regular insulin endpointgoal 0. In addition to timely identification of the precipitating cause, the first step in acute management of these disorders includes aggressive administration of intravenous fluids with appropriate replacement of electrolytes primarily potassium. Label or block print skmr009 aug 12 ijmrn gender surname given names d. Updates in the management of diabetic ketoacidosis the. Patient is alert and demonstrates interest in eating b. Download pdf of the guidelines for diabetes in pregnancy. 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.
Because there is considerable individual variability in presentation. Blood glucose bg 200 mgdl acidosis bicarbonate management diabetic ketoacidosis dka in adults and adolescents admitted under adult medical care only. Diabetic ketoacidosis symptoms, diagnosis and treatment. Blood glucose is routinely checked at the bedside, but portable ketone meters now also allow bedside measurement of blood ketones 3betahydroxybutyrate. Diabetic ketoacidosis dka management algorithm adult patients. It is characterised by absolute insulin deficiency and is the most common acute hyperglycaemic complication of type 1 diabetes mellitus. Research design and methods a total of 45 consecutive patients admitted with dka. Diabetic ketoacidosis dka care guidelines emergency. This protocol is to be used for the management of diabetic ketoacidosis dka in adults over the age of 16. Insulin infusion should be continued until acidosis has resolved, as demonstrated by ph 7. Near patient testing for the ketones is now readily available for monitoring allowing for a shift away from using glucose levels to drive treatment decisions in the management of dka. Clinical information systems using registries that can provide patientspeci. Treatment of diabetic ketoacidosis with subcutaneous insulin.
Sep 15, 20 in the dkahhs management protocol, regular insulin administered by i. Diabetic ketoacidosis can occur in persons of all ages, with 14 percent of cases occurring in. Whatyoushouldknow diabeticketoacidosis dkaisacommon,serious,andpreventablecomplicationoftype1diabetes,withamortalityof35%. Diabetic ketoacidosis dka is the metabolic abnormality of type 1 diabetes. Experienced nursing staff trained in dka management written guidelines for dka management access to laboratories that can provide frequent and timely measurements of biochemical variables. In patients aged 16 years presenting with dka, the management of dka should be discussed with relevant paediatric staff. If a patient has elevated bgl and ketones but is not acidotic they need to be closely monitored and agressively managed to prevent progression to dka. In the last decade, however, there has been a change in the way patients with dka present clinically and in addition there has been rapid development of nearpatient testing technology. Joint british diabetes societies inpatient care group. The management of diabetic ketoacidosis in adults our. The 2020 standards of medical care in diabetes includes all of adas current clinical practice recommendations and is intended to provide clinicians, patients, researchers, payers, and others with the components of diabetes care, general treatment goals, and tools to evaluate the quality of care. Treatment of diabetic ketoacidosis with subcutaneous. Diabetic ketoacidosis is characterized by a serum glucose level greater than 250 mg per dl, a ph less than 7.
Initiate dka order set phase i in pregnancy utilize ob dka order set. If there is no improvement as above, then the friii rate should be increased see management of dka, appendix 4 3. Dka guideline for diagnosis hhs guideline for diagnosis plasma glucose 250 mgdl arterial ph 12 plasma glucose 600 mgdl serum osmolality 320 mosmkg arterial ph 7. Arterial blood gas results rarely influence emergency physician management of patients.
Decrease rate of change of insulin infusion by 50% if blood glucose decreases by 100 mgdl per hour and notify physician. The joslin guideline for detection and management of diabetes in pregnancy is designed to assist internal medicine specialists, endocrinologists and obstetricians in individualizing the care of and setting goals for women with preexisting diabetes who are pregnant or planning pregnancy. Guidelines for the management of patients with dka and hhs. Decision support basing care on evidencebased, effective care guidelines 4. Diabetic ketoacidosis and hyperosmolar hyperglycemic.
Diabetic ketoacidosis dka is the most common hyperglycemic emergency in patients with diabetes. Management of diabetic ketoacidosis in adults age 16. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome hhs are life threatening complications that occur in patients with diabetes. Comparison of blood gas and acidbase measurements in arterial and venous blood samples in patients with uremic acidosis and diabetic ketoacidosis in the emergency room. Insulin protocols for managing dka critical care veterinary. Ispad 2009, mcgeoch 2007, savage 2006, bsped 2004, kitabchi 2009. Nurse practitioners are well positioned to promote patient education, self management, and individualized patient care. The 2009 american diabetes association ada position statement on hyperglycaemic emergencies in adult patients with diabetes details the management of diabetic ketoacidosis dka and hyperosmolar hyperglycaemia state. Criteria and overview pathophysiology of dka explanation of evidence ratings summary of version changes inclusion criteria dka is defined as need all 3 criteria. Management of diabetic ketoacidosis in children and. To transfer from iv to sc, continue iv insulin infusion for 1 to 2 hours after sc insulin is begun to. Objectives in 20, the association, now diabetes canada, published national clinical practice guidelines for the effective management of diabetic ketoacidosis and hyperosmolar hyperglycemic. A potential complication of treatment with sodiumglucose cotransporter 2 inhibition. Objective in this prospective, randomized, open trial, we compared the efficacy and safety of aspart insulin given subcutaneously at different time intervals to a standard lowdose intravenous iv infusion protocol of regular insulin in patients with uncomplicated diabetic ketoacidosis dka.
Identify and treat the cause of the dka precipitation. Flow chart for diabetic ketoacidosis in adults management of. In response to this imbalance, normal physiologic mechanisms are exaggerated, resulting in hyperglycemia, hyperosmolality, ketosis, and acidosis. Diabetic ketoacidosis dka critical care guideline two. Management of diabetic ketoacidosis in adults clinical. Management of diabetic ketoacidosis in adults age 16 years. Standards of medical care in diabetes2019 abridged for. When your cells dont get the glucose they need for energy, your body begins to burn fat for energy, which produces ketones. Adult dka management these recommendations do not take into account individual patient situations, and do not substitute for clinical judgment. Access to laboratory services for frequent and timely evaluation of biochemical variables. Understand the etiology of diabetic ketoacidosis dka.