Download Diabetic Ketoacidosis (DKA)

13:30-14:30
Diabetic Ketoacidosis
14:30-15:15
Oxygen Therapy
15:15-15:30
BREAK
15:30-16:30
Sepsis
25-year-old male with type 1 diabetes
lantus 26 units ON and novorapid 12 units TDS
recurrent attendances with DKA
admitted with 24h history of vomiting and
abdominal pain
 on admission;




›
›
›
›
CBG 18mmol/l
blood ketones 6.7mmol/l
pH 7.11
bicarbonate 9mmol/l
IS THIS DKA?
1.
Diabetes
›
2.
Ketosis
›
3.
CBG >11.1 mmol/l OR known diabetes
capillary blood ketones ≥3.0mmol/l OR urine ketones ≥3+
Acidosis
›
pH <7.30 OR bicarbonate ≤15mmol/l

have to have all 3 (high BMs plus ketones without acidosis ≠ DKA)

CBG may be relatively normal e.g. pregnancy (euglycaemic DKA)

many unwell patients with T2DM have acidosis and ketosis (e.g. from
vomiting, sepsis and renal failure) ≠ DKA
1.
Fluid Resuscitation
2.
Clearance of ketones and resolution of acidosis - insulin
3.
Prevention and treatment of low K+ (hypokalaemia)
4.
Identification and treatment of precipitating cause
5.
Monitoring (ketones, glucose, K+, other complications)
6.
Patient education and referral to diabetes specialist team
NOT getting the BM down as quickly as possible!
•
fluid deficit in DKA up to 100ml/kg =7l for 70kg person (more if sepsis)
•
deficits in sodium (10mmol/kg), chloride and potassium (3-5mmol/kg)
•
aim to correct over 24h using 0.9% saline

›
1l stat
›
2l over next 4h (500ml/h)
›
2l over next 8h (250ml/h)
›
2l over next 16h (125ml/h)
start 10% glucose infusion at 125ml/h when CBG <14mmol/l
›
0.9% saline should usually continue alongside the glucose infusion
DO NOT stop 0.9% saline when starting 10% glucose within first
24h as dextrose will not replace intravascular volume
•
50 units actrapid in 50ml 0.9% saline giving a 1unit/ml solution
•
FIXED RATE IV INSULIN INFUSION (FRIVII)
› start at 0.1 units/kg/h = 7 units/h = 7ml/h in a 70kg person
› NOT variable rate IV insulin infusion (VRIVII, ‘sliding scale’)
› rate of insulin does NOT go up/down depending on CBG (BM)
•
aim for fall in ketones of ≥0.5mmol/h
› fall in blood glucose of 3mmol/h NOT as important
•
if this is not being achieved i.e. ketones not falling by 0.5mmol/h
› check insulin infusion (rate, lines, venflon, volume TBI)
› increase insulin infusion rate by 1unit (1ml)/h and monitor
•
if patient takes long-acting insulin e.g. Lantus® or Levemir ensure this is
written on drug chart and is given ALONGSIDE the IV insulin infusion
•
if patient is normally on a SC insulin infusion pump ensure this is set to basal
rate only BEFORE starting the DKA protocol
•
FRIVII can be stopped when BOTH ketosis and acidosis have resolved i.e. pH
>7.30 AND ketones <0.3mmol/l
›
if patient eating and drinking switch to normal SC insulin (continue IV insulin
for 30-60 minutes overlap AFTER first SC insulin dose)
›
if patient not E&D, vomiting or septic switch to VRIVII protocol (‘sliding scale’)
•
although K+ is frequently normal on admission, total body stores of K+ are
usually low and serum potassium level will fall rapidly after starting IV insulin
•
first litre of IV fluid usually given stat without adding any KCl
•
potassium should be added to subsequent bags depending on repeated
measurements of serum K+
•
check VBG +/- U&E at least 4h during first 24h
Serum Potassium (mmol/l)
Amount of KCl to add per litre of
fluid (mmol/l)
≥5.5
0
4.5-5.5
20
<4.5
40
•
new diagnosis of T1DM
•
infection/sepsis
•
MI
•
missed insulin doses in known T1DM
›

often intentional as a form of repeated self-harm behaviour
bloods, CXR, urinalysis, ECG, blood cultures, stool
cultures etc.
•
hourly obs including GCS/urine output (consider catheter) if severe DKA
•
hourly CBG AND blood ketones (document religiously!)
•
fluid balance chart
•
keep checking…..
•
–
insulin running at correct rate and no problems with pump etc.
–
fluids are being given in time with prescribed schedule
gently ‘remind’ doctors…..
–
to repeat U&E plus VBG (at least every 4h)
–
to increase insulin rate if ketones not falling adequately
–
to add potassium to fluids
•
hypokalaemia – risk of life threatening arrhythmias
•
cerebral oedema (adolescents and children)
•
pneumonia (including aspiration)
•
MI
•
venous thromboembolism (ensure Clexane® is prescribed)
•
hypoglycaemia
•
hypomagnesaemia and hypophosphataemia
•
hypoxaemia and ARDS
MORTALITY still 2-5%
•
diagnosed with DKA
•
3L of 0.9% saline written up over first 4h
•
started on FRIVII at 6units(ml)/h (60kg)
•
26 units of lantus prescribed on drug chart
•
after 2h blood ketones are 6.3mmol/L (6.7)
•
insulin being delivered at correct rate
•
insulin rate increased to 7units(ml)/h
•
2h later ketones 4.2mmol/L and CBG 12mmol/L
•
second cannula sited and 10% glucose started at 125ml/h in
addition to 0.9% saline continued
•
nurse repeats VBG and informs doctor that K+ is 3.8mmol/l
•
40mmol KCl added to next 2 litres of 0.9% NaCl
•
CXR shows R basal pneumonia; IV abx given
•
after 12h VBG is repeated and shows pH 7.33 and
bicarbonate 18mmol/l; blood ketones now 0.2mmol/l
•
patient still not eating and drinking
•
VRIVII (‘sliding scale’) commenced and patient transferred to
Ward 9 for ongoing care
•
doctor, doctor the ketones/BMs are not falling…
–
insulin infusion running at 0.1ml/h rather than 7ml/h (0.1u/kg/h)
–
line from insulin pump clamped off
–
venflon removed and trickling insulin into patient’s mattress
–
pump constantly alarming so only 14 units given over 6h (42 units)
•
patient collapsed in toilet due to severe hypoglycaemia; SC insulin pump
still running despite being started on FRIVII
•
no IV insulin running for 4h as nurse wanted to ‘wait until decision made
on Consultant ward round’; patient rebounded back into DKA
•
long-acting insulin not written up on drug chart
•
0.9% saline stopped when 10% glucose commenced before patient
adequately rehydrated
•
VRIVII (‘sliding scale’) being used instead of FRIVII
•
ketones not regularly being checked with BMs
•
20 consecutive cases of DKA admitted to AMU
•
not 1 case managed completely in accordance with 2010 JBDS DKA guidelines
•
inadequate initial fluid resuscitation in 45%
•
10% glucose not commenced when BM <14mmol/l in 50%
•
FRIVII not delivered or delivered incorrectly in 30%
•
CBG and ketones not checked/documented hourly in 35%
•
failure to adjust FRIVII appropriately in 55%
•
long acting SC insulin not prescribed in 50%
•
insulin written up in 5 different places (sometimes multiple prescriptions)
•
inadequate potassium replacement in 70%
•
no septic screen in 65%
•
inadequate repeat U&E/VBG in 70%
•
poor awareness/understanding of new DKA
guidelines (medical and nursing)
•
confusion regarding the use of FRIVII vs VRIVII and
the need for continued rehydration after
commencing 10% glucose
•
multiple versions of DKA guideline in circulation
•
documentation of IV insulin, IV fluids, BMs/ketones
in multiple different places on drug charts, IV fluid
charts etc.
•
tends to affect older type 2 diabetics
•
glucose often much higher than in DKA (usually >30mmol/l)
•
more profound dehydration (sodium very high and fluid deficit >10l)
•
acidosis not required for diagnosis (often acidotic due to sepsis or AKI)
•
ketosis may be present due to starvation/acute illness (rarely >3.0mmol/l)
•
fluid deficit should be corrected more slowly e.g. over 72h
•
FRIVII is not required (use VRIVII, 50% of usual dose if insulin naïve)
•
10% dextrose is rarely required
•
invariably associated with severe precipitating illness e.g. MI, sepsis
•
prognosis much worse (mortality up to 50%)

we need to improve – Nurses and ACPs need to lead management

fluid resuscitation is the most important part of initial treatment

fixed rate IV insulin infusion (FRIVII) NOT sliding scale (VRIVII)

check CBG (BM) and blood ketones HOURLY

if ketones not falling by 0.5mmol/h check pump and lines BEFORE increasing
insulin rate by 1unit(ml)/h

give long acting SC insulin AS WELL AS IV insulin

remember to check patients for SC insulin infusion pumps

start 10% glucose when CBG <14mmol/l but CONTINUE 0.9% saline AS WELL

frequent monitoring/obs and repeat U&E/VBG

ADEQUATE potassium replacement

identify and treat cause, monitor for complications