Diabetic ketoacidosis in ADULTS
Confirm diabetic ketoacidosis -
pH < 7.3
- hyperosmolar non-ketotic coma in the elderly -
may have + or ++ urinary ketones but are not acidotic.
The combined care
protocol and chart must be printed off and used to prescribe and
record individual management for every patient
Aims and principles
1. Correction of ketoacidosis by
* 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. Replace lost fluid and electrolytes
2. Controlled, steady correction of abnormalities
* aim for glucose fall 3-5 mmol/l/hr only
* allow acidosis to correct as above
Do not consider bicarbonate unless pH < 6.9 If necessary use IL 1.26% solution + 20 mmol KCl
4. Establish and treat cause
Emergency department management DKA
Initial assessment |
| For DKA |
For
underlying cause |
| Urinary ketones
(Do not catheterise unless
comatose)
Lab serum glucose
Arterial pH, PO2, PCO2, HCO3-
U & E
|
ECG
FBC
Urinary and blood cultures
Pregnancy test
CXR |
|
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| Patient details / addressograph
Name
Address
D.O.B
Ward
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Initial treatment |
| A) Replacement of fluid and electrolyte losses
Normal saline +/- KCL until hydration restored
(See documentation
chart page 2 )
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| B) Correction of ketoacidosis
i.v. insulin +/- 10% dextrose until venous pH > 7.3
(insulin infusion = 4 - 6 units /
hr = 0.05 - 0.1 units/kg/hr) (See documentation
chart page 3)
Aim for glucose fall 3 - 5 mmol/hour only
Do not give bicarbonate unless pH < 6.9
(SpR or consultant decision only) |
|
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C) Treat
underlying
cause |
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Monitoring and continued care |
|
Biochemistry
One hour after
starting treatment and
2 hourly
until acidosis corrected
Venous pH
(in
heparinised or ABG syringe)
Plasma glucose
Na+, K+, HCO3-
Record results in documentation
chart page 4 |
|
|
Observations
Pulse and BP hourly (Notify Dr
if pulse > 100/min or systolic BP < 100 mmHg)
Hourly Neuro Obs if drowsy (Notify Dr
if any fall in GCS or pupillary size)
Capillary blood glucose hourly
Fluid balance chart - with hourly
urine output
Ask patient to pass urine every hour. If
no urine after 2 hours - catheter
Withdraw catheter if good urine output after 1 hour
Contact Dr if hourly urine < 20 ml or
< 30 ml for two consecutive hours |
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| Other measures NG Tube if vomiting and impairment of conscious level
Coma management as indicated |
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Recovery phase (this is when most problems
occur) |
| Continue IV regimen with infusion rate
constant until acidosis corrected (pH > 7.3), then |
| If patient eating: |
Give s.c.. insulin (6 - 8 units actrapid or patient's
normal dose) 30 min before meal. Discontinue i.v. 1 hour after
s.c. insulin given and meal eaten |
If patient nauseated
or anorectic: |
Continue 10% dextrose infusion (75 ml/hr) with KCL and
i.v. insulin at rate necessary to control blood glucose |
| When patient eating and drinking normally |
| Newly diagnosed: |
Start twice daily Mixtard 30: 8 - 12 units b.d.
and adjust dose as necessary
Contact diabetes medical firm and specialist nurses for further
management |
| Known IDDM: |
Recommence normal insulin and adjust as necessary.
Consider temporary se of q.d.s regimen if precipitating factor means
that the patient is still unwell |
| Monitor with capillary blood glucose and
urine testing for ketones before meals and bedtime |
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Most common errors in management of diabetic
ketoacidosis |
Insulin pump not connected to patient
Failure to review fluid replacement, particularly in the elderly
Failure to act on results (eg serum potassium) |
Loss of continuity or attention in recovery phase
Stopping IV insulin before SC given
Failure to identify underlying cause |
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| Print protocol (including
documentation sheet and insulin sliding scale) |
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Links
NICE Guidelines Mx Diabetes
in Adults and Children 2004 Local Copy, Quick reference Local Copy.
