Joint British Diabetes Societies Inpatient Care Group British Diabetes Societies Inpatient Care Group ... org.uk Diabetic ketoacidosis (DKA), ... version of this document at

Joint British Diabetes SocietiesInpatient Care Group

The Management of DiabeticKetoacidosis in Adults

Second Edition

Update: September 2013

This document is coded JBDS 02 in the series of JBDS documents

Other JBDS documents:The management of the hyperosmolar hyperglycaemic state (HHS) in adults with diabetes. August 2012 - JBDS 06

Glycaemic management during the inpatient enteral feeding of stroke patients with diabetes. June 2012 - JBDS 05

Self-management of diabetes in hospital. March 2012 - JBDS 04

The management of adults with diabetes undergoing surgery and elective procedures: improving standards. April 2011 - JBDS 03

The hospital management of hypoglycaemia in adults with diabetes mellitus. Revised September2013 - JBDS 01

These documents are available to download from the ABCD website athttp://www.diabetologists-abcd.org.uk/JBDS/JBDS.htm and the Diabetes UK website atwww.diabetes.org.uk

3 The references can be found in the on-line version of this document at www.diabetologists-abcd.org.uk/JBDS/JBDS.htm or

www.diabetes.org.uk

Revision Group

Lead authorshipDr Ketan Dhatariya, Norfolk and Norwich University Hospital NHS Foundation TrustDr Mark Savage, Bendigo Health, Australia

Supporting organisationsTracy Kelly, Diabetes UKProfessor Mike Sampson (Norwich), Joint British Diabetes Societies (JBDS) InpatientCare Group ChairEsther Walden (Norwich), Diabetes Inpatient Specialist Nurse (DISN) UK Group Chair Dr Chris Walton (Hull), Association of British Clinical Diabetologists (ABCD) Chair

Writing groupAnne Claydon, Barts Health NHS Trust Dr Philip Dyer, Heart of England NHS Foundation TrustDr Philip Evans, Pontypridd and Rhondda NHS TrustDr Atir Khan, Hywel Dda Health BoardDr Anne Kilvert, Northampton General Hospital NHS TrustDr Nicky Leech, The Newcastle upon Tyne Hospitals NHS Foundation TrustDr Nicholas Levy, West Suffolk Hospitals NHS Foundation TrustDr Gerry Rayman, The Ipswich Hospitals NHS TrustDr Alan Rees, Cardiff and Vale University Health BoardDr Maggie Sinclair-Hammersley, Oxford University Hospitals NHS Trust

Thanks also to:Northern Irish DiabetologistsSociety of Acute MedicineWelsh Endocrine and Diabetes SocietyScottish Diabetes Group

We would also like to thank the service user representatives whose input hasinformed the development of these guidelines.

With special thanks to Christine Jones (DISN UK Group administrator, Norwich) forher administrative work and help with these guidelines and with JBDS – IP.

JBDS IP Group gratefully acknowledges the funding and administrative support fromNHS Diabetes.

4The references can be found in the on-line version of this document at www.diabetologists-abcd.org.uk/JBDS/JBDS.htm orwww.diabetes.org.uk

JBDS IP Review GroupDr Belinda Allan, Hull and East Yorkshire Hospital NHS TrustDr Hamish Courtney, Belfast Health and Social Care Trust, Northern IrelandDr Ketan Dhatariya, Norfolk and Norwich University Hospitals NHS Foundation TrustDr Daniel Flanagan, Plymouth Hospitals NHS TrustJune James, University Hospitals of Leicester NHS TrustTracy Kelly, Diabetes UKDr Rif Malik, King’s College Hospital NHS Foundation TrustDr Colin Perry, NHS Greater Glasgow and ClydeDr Gerry Rayman, The Ipswich Hospitals NHS TrustDr Stuart Ritchie, NHS LothianDr Aled Roberts, Cardiff and Vale University NHS TrustProfessor Mike Sampson (Norwich), Joint British Diabetes Societies (JBDS) InpatientCare Group ChairDr Maggie Sinclair-Hammersley, Oxford University Hospitals NHS TrustDebbie Stanisstreet, East and North Hertfordshire NHS TrustDr Jonathan Valabhji, National Clinical Director for Obesity and DiabetesEsther Walden, Norfolk and Norwich University Hospital NHS Foundation TrustDr Chris Walton, Hull and East Yorkshire Hospital NHS TrustDr Peter Winocour, East and North Hertfordshire NHS Trust

This document has been endorsed by the Intensive Care Society

British Society of Paediatric Endocrinology and Diabetes (BSPED) guidelines for themanagement of DKA in young people under the age of 18 years can be found at:http://www.bsped.org.uk/clinical/docs/DKAGuideline.pdf


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Page

Foreword 6

Introduction 8

Rationale for best practice 10

Controversial areas 13

Serious complications of DKA or its treatment 16

DKA pathway of care 17

Implementation and audit 23

References (in the on-line edition only)

Appendices 241. Conversion to subcutaneous insulin2. Joint British Societies Audit Standards

Contents

The references can be found in the on-line version of this document at www.diabetologists-abcd.org.uk/JBDS/JBDS.htm orwww.diabetes.org.uk

Diabetic ketoacidosis (DKA), though preventable, remains a frequent and life threatening complication oftype 1 diabetes. Unfortunately, errors in its management are not uncommon and importantly areassociated with significant morbidity and mortality. Most acute hospitals have guidelines for themanagement of DKA but it is not unusual to find these out of date and at variance to those of otherhospitals. Even when specific hospital guidelines are available audits have shown that adherence to andindeed the use of these is variable amongst the admitting teams. These teams infrequently refer early tothe diabetes specialist team and it is not uncommon for the most junior member of the admitting team,who is least likely to be aware of the hospital guidance, to be given responsibility for the initialmanagement of this complex and challenging condition.

To address these issues the Joint British Diabetes Societies (JBDS), supported by NHS Diabetes, hasproduced this revision of the 2010 guidance developed by a multidisciplinary group of practicingspecialists with considerable experience in this area. Where possible the guidance is evidence based butalso draws from accumulated professional experience. A number of modifications have been madeincluding addition of the criteria to define resolution of DKA and the option to continue human basalinsulins in patients who normally take these to manage their day-to-day diabetes.

The management is clearly presented and divided into a number of key steps in the care pathway; the firsthour, the next six hours, next twelve hours etc.

Importantly, conversion to subcutaneous insulin and preparing for discharge home are included. Audit isencouraged against defined standards.

The guideline is clearly written and accompanied by a practical and easy to follow flow chart to be used inadmitting departments and wards managing DKA. Also included online in the update is an example of anIntegrated Care Pathway, this can be modified for local use and is not presented as a fait accompli.

The authors should be congratulated on their achievement. These guidelines are recommended to alldiabetes hospital teams for rapid introduction and for acceptance as the national guideline for managingDKA. Their widespread introduction should significantly improve the care of people admitted with DKA.

Since this guideline was launched in March 2010, over 5000 copies of the guidelines have beendistributed by NHS Diabetes, with countless more being downloaded from the website. In addition, thesubsequent publication in Diabetic Medicine (Savage MW et al, Diabetic Medicine 2011;28(5):508-515)has been cited numerous times. Furthermore in the 2012 National Diabetes Inpatient Audit 170 of 216hospitals reported introducing new DKA guidelines with the majority adopting or modifying the JBDSguidelines.

Dr G RaymanNHS Diabetes Clinical Lead for Inpatient Diabetes CareMarch 2013

6

Foreword

Acronyms:NPSA – National Patients Safety Agency

ISPAD – International Society for Pediatric and Adolescent Diabetes

BSPED – British Society of Paediatric Endocrinology and Diabetes

FRIII – Fixed rate intravenous insulin infusion

VRIII – Variable rate intravenous insulin infusion


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There are several currently available national andinternational guidelines for the management ofDiabetic Ketoacidosis (DKA) in both adults andchildren 1-6.

In the last decade, however, there has been achange in the way patients with DKA presentclinically and in addition there has been rapiddevelopment of near-patient testing technology.Until recently there was no easily available assayfor ketone bodies hence capillary glucose, venouspH and bicarbonate were used to diagnose andmonitor response to treatment in DKA. Near patient testing for 3-beta-hydroxybutyrate isnow readily available for the monitoring of theabnormal metabolite allowing for a shift awayfrom using glucose levels to drive treatmentdecisions in the management of DKA.

These guidelines have been developed to reflectthe development in technology and reflect newpractice in the UK. They are evidence based wherepossible but are also drawn from accumulatedprofessional knowledge and consensus agreement.They are intended for use by any health careprofessional that manages DKA in adults.

Definition and diagnosisDKA consists of the biochemical triad ofketonaemia (ketosis), hyperglycaemia, andacidaemia.

PathophysiologyDiabetic ketoacidosis (DKA) is a complexdisordered metabolic state characterised byhyperglycaemia, acidosis, and ketonaemia. DKAusually occurs as a consequence of absolute orrelative insulin deficiency that is accompanied byan increase in counter regulatory hormones (i.e.,glucagon, cortisol, growth hormone,catecholamines). This type of hormonal imbalanceenhances hepatic gluconeogenesis andglycogenolysis resulting in severe hyperglycaemia.Enhanced lipolysis increases serum free fatty acidsthat are then metabolised as an alternative energysource in the process of ketogenesis 7. This results

in accumulation of large quantities of ketonebodies and subsequent metabolic acidosis. Ketones include acetone, 3-beta-hydroxybutyrate,and acetoacetate. The predominant ketone in DKAis 3-beta-hydroxybutyrate.

DKA has been considered to be indicative, or evendiagnostic, of type 1 diabetes, but increasinglythere are cases of ketone-prone type 2 diabetesbeing recognised. However, the initial treatment isthe same.

There are several mechanisms responsible for fluiddepletion in DKA. These include osmotic diuresisdue to hyperglycaemia, vomiting - commonlyassociated with DKA - and eventually, inability totake in fluid due to a diminished level ofconsciousness. Electrolyte shifts and depletion arein part related to the osmotic diuresis.Hyperkalaemia and hypokalaemia need particularattention.

EpidemiologyThe true incidence is difficult to establish.Population based studies range from 4.6 to 8episodes per 1,000 patients with diabetes 8,9. DKA remains a significant clinical problem in spiteof improvements in diabetes care 10,11. In the USAthe prevalence has risen 12, whilst mortality hasfallen 13,14. Importantly however, the 2012 NationalDiabetes Inpatient Audit also found that a largenumber of people developed DKA whilst already inhospital, thus this complication is not just found atthe ‘front door’ 15.

Mortality and morbidityAn improved understanding of thepathophysiology of DKA together with closemonitoring and correction of electrolytes hasresulted in a significant reduction in the overallmortality rate from this life-threatening condition.Mortality rates have fallen significantly in the last20 years from 7.96% to 0.67% 13,14.

Introduction

8

DIAGNOSIS:Ketonaemia > 3.0mmol/L or significant ketonuria (more than 2+ on standard urine sticks)Blood glucose > 11.0mmol/L or known diabetes mellitus Bicarbonate (HCO3-) < 15.0mmol/L and/or venous pH < 7.3

9

The mortality rate is still high in developingcountries and among non hospitalised patients 16.This high mortality rate illustrates the necessity ofearly diagnosis and the implementation of effectiveprevention programmes.

Cerebral oedema remains the most common causeof mortality, particularly in young children andadolescents. The main causes of mortality in theadult population include severe hypokalaemia,adult respiratory distress syndrome, and co-morbidstates such as pneumonia, acute myocardialinfarction and sepsis 17.

The references can be found in the on-line version of this document at www.diabetologists-abcd.org.uk/JBDS/JBDS.htm or

www.diabetes.org.uk


Ketones and acidosisBefore the publication of the first edition of theseguidelines, management of DKA focused onlowering the elevated blood glucose with fluids andinsulin, using arterial pH and serum bicarbonate toassess metabolic improvement. This was based onthe assumption that this would efficiently suppressketogenesis and reverse acidosis. This strategyrecognised that blood glucose is only a surrogate forthe underlying metabolic abnormality. Recentdevelopments allow us to focus on the underlyingmetabolic abnormality, ketonaemia, which simplifiestreatment of those who present with modestelevation of blood glucose but with an acidosissecondary to ketonaemia - ‘euglycaemic diabeticketoacidosis’ 8,18,19. This clinical presentation is notuncommon and should not be forgotten whenglucose levels are not particularly raised. Improved patient education with increased bloodglucose and ketone monitoring has led to partialtreatment of DKA prior to admission withconsequent lower blood glucose levels atpresentation.

Bedside Monitoring These guidelines recommend that management bebased on bedside monitoring of patients with DKA.Blood glucose is routinely checked at the bedside,but portable ketone meters now also allow bedsidemeasurement of blood ketones (3-beta-hydroxybutyrate). This is an important advance in themanagement of DKA 20-25. A recent meta-analysiscomparing the use of blood ketones versus urinaryketones in DKA showed that blood measurementswere associated with reduced emergencydepartment assessment, hospitalisations and ashorter time to recovery, thus potentially savingmoney 26. The resolution of DKA depends upon thesuppression of ketonaemia, therefore measurementof blood ketones now represents best practice inmonitoring the response to treatment 27.

Access to blood gas and blood electrolytemeasurement is now relatively easy and availablewithin a few minutes of blood being taken. Therefore glucose, ketones and electrolytes, includingbicarbonate and venous pH, should be assessed at ornear the bedside.

This recommendation raises important issues:

• Staff must be trained in the use of blood glucoseand ketone meters

• The meters should be subject to rigorous qualityassurance

• Laboratory measurement will be required in certaincircumstances, such as when blood glucose orketone meters are ‘out of range’

It is recognised that almost all units now have accessto ketone meters. However, guidance is also given onmonitoring treatment using the rate of rise ofbicarbonate and fall in blood glucose as alternativemeasures.

The involvement of Diabetes SpecialistTeamsThe diabetes specialist team must always be involvedin the care of those admitted to hospital with DKA.Their involvement shortens patient stay and improvessafety 28-31. This should occur as soon as possibleduring the acute phase but will depend on localcircumstances. In line with the recently introducedBest Practice Tariff for DKA, specialists must also beinvolved in the assessment of the precipitating causeof DKA, management, discharge, and follow up 32.This will include assessment of the patient’sunderstanding of diabetes plus their attitudes andbeliefs as well as ensuring the provision of structurededucation. Specialist involvement is essential toensure regular audit and continuous qualityimprovement in the implementation of DKAguidelines. The practice of admitting, treating anddischarging patients with DKA without theinvolvement of the diabetes specialist team is unsafe

Rationale for best practiceThe new paradigm

11

and likely to compromise safe patient care. This is agovernance issue 33.

Recommended changes in management listedin the 2010 guidance

• Measurement of blood ketones, venous (notarterial) pH and bicarbonate and their use astreatment markers

• Monitoring of ketones and glucose using bedsidemeters when available and operating within theirquality assurance range

• Replacing ‘sliding scale’ insulin with weight-basedfixed rate intravenous insulin infusion (FRIII)

• Use of venous blood rather than arterial blood inblood gas analysers

• Monitoring of electrolytes on the blood gasanalyser with intermittent laboratory confirmation

• Continuation of long acting basal insulinanalogues as normal

• Involvement of the diabetes specialist team as soonas possible

Uptake of the 2010 guideline

The National (England mainly) Inpatient DiabetesAudit 34 has shown that 170 of 216 hospitalsreported introducing new DKA guidelines, with themajority adopting or modifying the JBDS guidelines.However, a recent audit of Intensive Care and HighDependency Units in East Anglia demonstrated thatfor the sickest patients there remains controversyover the fluid regimen advocated 35. This currentupdate acknowledges these differences of opinion.

Modification for 2013

• Some units have been continuing human basalinsulin in patients taking these insulins (Humulin I®,Insulatard® , Insuman Basal®) with no apparentproblems – it is recommended that this beconsidered for such patients - see ControversialAreas

• A maximum initial insulin infusion rate of 15 unitsper hour is recommended 36,37

• Resolution of DKA is defined as pH > 7.3 units;bicarbonate > 15.0mmol/L; and blood ketone level< 0.6mmol/L (rather than < 0.3mmol/L), in order toavoid re-starting the FRIII if the ketone levelrebounds upon discontinuation of the FRIII

• Newly presenting type 1 patients should be givenLantus® or Levemir® at a dose of 0.25 units per kgonce daily subcutaneously. However, local policiesshould be followed when deciding which insulin(s)to start. Diabetes specialist teams should beinvolved in this decision

General management issuesFluid administration and deficits

There is universal agreement that the most importantinitial therapeutic intervention in DKA is appropriatefluid replacement followed by insulin administration.

The main aims for fluid replacement are:

• Restoration of circulatory volume

• Clearance of ketones

• Correction of electrolyte imbalance

The typical fluid and electrolyte deficits are shown inthe table below. For example, an adult weighing70kg presenting with DKA may be up to 7 litres indeficit. This should be replaced as crystalloid. In patients with kidney failure or heart failure, as wellas the elderly and adolescents, the rate and volumeof fluid replacement may need to be modified. Theaim of the first few litres of fluid is to correct anyhypotension, replenish the intravascular deficit, andcounteract the effects of the osmotic diuresis withcorrection of the electrolyte disturbance.

Table: Typical deficits in DKA in adults

Water - 100ml/kgSodium - 7-10mmol/kgChloride - 3-5mmol/kgPotassium - 3-5mmol/kg

The type of fluid to be used is discussed in detail inControversial Areas.

Insulin therapy

A fixed rate intravenous insulin infusion (FRIII)calculated on 0.1 units/per kilogram body weight isrecommended (see table below to assist). It may benecessary to estimate the weight of the patient. See Controversial Areas. Insulin has several effects 38,but the following are the most important whentreating DKA:

• Suppression of ketogenesis

• Reduction of blood glucose

• Correction of electrolyte disturbance


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12

A table has been introduced to assist in thecalculation of the insulin dose for weight:

Metabolic treatment targets

The recommended targets are

• Reduction of the blood ketone concentration by0.5mmol/L/hour

• Increase the venous bicarbonate by3.0mmol/L/hour

• Reduce capillary blood glucose by 3.0mmol/L/hour

• Maintain potassium between 4.0 and 5.5mmol/L

If these rates are not achieved, then the FRIII rateshould be increased (see Management of DKASection B, Action 2).

Intravenous glucose concentration

The management should be focused on clearingketones as well as normalising blood glucose. It is often necessary to administer an intravenousinfusion of 10% glucose in order to avoidhypoglycaemia and permit the continuation of a FRIIIto suppress ketogenesis. Introduction of 10%glucose is recommended when the blood glucosefalls below 14.0mmol/L. It is important to continue0.9% sodium chloride solution to correct circulatoryvolume. It is quite often necessary to infuse thesesolutions concurrently (Section B, Action 2). Glucose should be continued until the patient iseating and drinking normally.

Special patient groups

The following groups of patients need specialist inputas soon as possible and special attention needs to bepaid to their fluid balance.

• Elderly

• Pregnant

• Young people 18 to 25 years of age (see sectionon cerebral oedema)

• Heart or kidney failure

• Other serious co-morbidities

Patient considerations

In line with several aspects of the Best Practice Tariff,patients with diabetes who are admitted with DKAshould be referred to the diabetes specialist teamwithin one working day and should be counselledabout the precipitating cause and early warningsymptoms. Failure to do so is a missed educationalopportunity. Things to consider are:

• Identification of precipitating factor(s) e.g. infectionor omission of insulin injections

• Review of their usual glycaemic control

• Review of their injection technique / blood glucosemonitoring / equipment / injection sites

• Prevention of recurrence e.g. provision of writtensick day rules

• Insulin ineffective e.g. the patient’s own insulinmay be expired or denatured. This should bechecked prior to reuse

• Assess the need for, and where necessary,provision of handheld ketone meters for use athome

• Provision of a contact number on how to contactthe diabetes specialist team out of hours

• Education of health care professionals on themanagement of ketonaemia

• Provision of a written care plan – allowing thepatient to have an active role in their own diabetesmanagement, with a copy of this going to their GP


WEIGHT in KG INSULIN DOSE PER HOUR (Units)

60-69 6

70-79 7

80-89 8

90-99 9

100-109 10

110-119 11

120-130 12

130-139 13

140-150 14

>150 15 (any dose higher than this should be on the advice of theDiabetes Specialist Team)

13

Controversial areas


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The clinical assessment and aims of treatment inthe management of DKA are not controversial.However, there is still disagreement about theoptimum treatment regimen and where theevidence base is not strong, recommendations arebased on consensus and experience. Some of themore controversial points will now be consideredand good practice recommendations are made.The recommendations are given first followed bythe rationale.

Recommendations1. Measure venous rather than arterial bicarbonate

and pH

2. Blood ketone meters should be used for nearpatient testing

3. Crystalloid rather than colloid solutions arerecommended for fluid resuscitation

4. Cautious fluid replacement in young adults

5. 0.9% sodium chloride solution is therecommended fluid of choice on the generalmedical ward (recommended as it iscommercially available with premixed potassiumchloride, and therefore complies with NPSArecommendation)

6. Subcutaneous long-acting analogue/humaninsulin should be continued

7. Insulin should be administered as a FRIIIcalculated on body weight

8. Do not use a priming (bolus) dose of insulin

9. Bicarbonate administration is not recommendedroutinely

10. Phosphate should not be supplementedroutinely

11. What should the rate of glucose lowering be?

1. Arterial or venous measurements?

Over the last few years evidence has accumulatedto show that the difference between venous andarterial pH is 0.02-0.15 pH units and the differencebetween arterial and venous bicarbonate is

1.88mmol/L 39-41. This will neither affect thediagnosis nor management of DKA and it is notnecessary to use arterial blood to measure acidbase status 42. Venous blood can be used inportable and fixed blood gas analysers andtherefore venous measurements (pH, bicarbonate,and potassium) are easily obtained in mostadmitting units. Arterial line insertion should only be performed ifits use will influence management, i.e. for frequentarterial oxygen level measurements or monitoringblood pressure in the critically unwell patient.

2. Blood ketone measurement?

Ketonaemia is the hallmark of DKA. Frequentrepeated measurement of blood 3-beta-hydroxybutyrate has recently become a practicaloption due to the availability of bedside meterswhich can measure blood ketone levels.Compelling evidence supports the use of thistechnology for diagnosis and management of DKA20,21,24-26. The resolution of DKA depends upon thesuppression of ketonaemia and measurement ofblood ketones now represents best practice inmonitoring the response to treatment. Whilst highlevels of ketones might not give consistent results,these levels are still well above the levels needed todiagnose and manage DKA and should notinterfere with management as outlined here 43.

3. Colloid versus crystalloid?

A recent critical care consensus document suggeststhat colloids should be avoided where possible dueto a potential risk of increased mortality andmorbidity associated with their use 44.Furthermore, a recent Cochrane review also didnot support the use of colloid in preference tocrystalloid fluid 45. Therefore, we recommend theuse of crystalloid fluid as the initial fluid of choice.

4. Rate of fluid replacement?

There is concern that rapid fluid replacement maylead to cerebral oedema in children and youngadults. National and international paediatric

6. Continuation of long-acting insulin analoguesand basal human insulins?

In the last few years the use of long acting basalinsulin analogues (Levemir®, Lantus®, and morerecently Tresiba®) has become widespread.Continuation of subcutaneous analogues duringthe initial management of DKA providesbackground insulin when the IV insulin isdiscontinued. This avoids rebound hyperglycaemiawhen IV insulin is stopped 49 and should avoidextending the length of stay. This only applies tolong acting analogues and does not obviate theneed to give short acting insulin beforediscontinuing the intravenous insulin infusion.

Clinical experience suggests that continuation ofpre-existing prescriptions of human basal insulins isalso safe; it is not presently recommended theseshould always be continued, but it is recognisedthat this is a course of action some units might

wish to undertake; audits of practice will helpclarify their use, but in the view of many expertsthere is not much difference between the onset ofaction and duration of actions of human basalinsulin compared with the long acting humananalogues 50.

7. Fixed-rate intravenous insulin infusion (FRIII)versus variable rate intravenous insulininfusion?

Patient demographics are changing and patientswith DKA are now more likely to be obese. They may also have other insulin-resistant statessuch as pregnancy. Evidence has led to the re-emergence of FRIII in adults in the USA andinternational paediatric practice 1,5,6.

Fixed dose(s) per kilogram body weight enablerapid blood ketone clearance, which is readily


guidelines recommend cautious fluid replacementover 48 hours. No randomised controlled trialsexist to guide decision making in this area. We therefore recommend cautious fluidreplacement in small young adults who are notshocked at presentation.

5. 0.9% sodium chloride solution or Hartmann’ssolution for resuscitation?

There has been much debate about the relativemerits of these two solutions 46. Two randomisedtrials published since the 2010 version of thisguideline have compared 0.9% sodium chloride

solution to Hartmann’s solution 47,48. Neither hasshown the superiority of one fluid over the other interms of clinical outcomes. We thereforerecommend that 0.9% sodium chloride with pre-mixed potassium chloride should be the defaultsolution for fluid resuscitation, because it iscompliant with NPSA recommendations.Furthermore, diabetes specialists and physicianshave a vast experience in the safe use of this fluid.We also recognise that many critical care units willprefer to use balanced crystalloids such asHartmann’s solution. This is acceptable providedlocal policies are followed for the safeadministration of additional potassium chloride.

Infusion solution Advantages Disadvantages

0.9% sodium chloride • Decades of clinical experience • Hyperchloraemic metabolic acidosis

• Readily available in clinical areas which may cause renal arteriolar

• Commercially available ready mixed vasoconstriction leading to oliguria with potassium at required concentrations, and a slowing of resolution of acidosis20mmol/L (0.15%) or 40mmol/L (0.3%)

• Supports safe practice with injectable potassium (NPSA compliant (NPSA alert 2002))

Compound sodium • Balanced crystalloid with minimal • Insufficient potassium if used alonetendency to hyperchloraemic metabolic • Not commercially available acidosis with adequate pre-mixed potassium.

Potassium addition in general clinicalareas is unsafe. (NPSA alert 2002)

• Unfamiliar and not routinely kept onmedical wards

14

monitored using bed-side ketone measurement.The fixed rate may need to be adjusted in insulinresistant states if the ketone concentration is notfalling fast enough, and/or the bicarbonate level isnot rising fast enough. (A study in England shouldshortly clarify whether the weight-based approachis superior, or not, to flat rate infusion of 6 unitsper hour. For now weight based insulin isrecommended).

8. Initiating treatment with a priming (bolus)dose of insulin?

A priming dose of insulin in the treatment in DKAis not necessary provided that the insulin infusionis started promptly at a dose of at least 0.1unit/kg/hour 6.

9. Intravenous bicarbonate?

Adequate fluid and insulin therapy will resolve theacidosis in DKA and the use of bicarbonate is notindicated 51-53. The acidosis may be an adaptiveresponse as it improves oxygen delivery to thetissues by causing a right shift of the oxygendissociation curve. Excessive bicarbonate maycause a rise in the CO2 partial pressure in thecerebrospinal fluid (CSF) and may lead to aparadoxical increase in CSF acidosis 51. In addition,the use of bicarbonate in DKA may delay the fall inblood lactate: pyruvate ratio and ketones whencompared to intravenous 0.9% sodium chloride

infusion 52. There is some evidence to suggest thatbicarbonate treatment may be implicated in thedevelopment of cerebral oedema in children andyoung adults 54.

10. Use of intravenous phosphate?

Whole-body phosphate deficits in DKA aresubstantial, averaging 1mmol/kg of body weight.There is no evidence of benefit of phosphatereplacement 55 thus we do not recommend theroutine measurement or replacement ofphosphate. However, in the presence of respiratoryand skeletal muscle weakness, phosphatemeasurement and replacement should beconsidered 56.

11. What should the rate of glucose lowering be?

The data from the studies published in the 1970s57,58 showed that using low dose insulin infusions(i.e. 0.1 units/Kg/hr) resulted in glucose levelscoming down at about the same rate as the highdose insulin given in the preceding decades, withglucose levels coming down by about 50-60% inthe first 4 hours. The theoretical risk of largeosmotic shifts due to rapid changes in plasmaglucose are very rare in DKA, and thus the safetyof using 0.1 unit/Kg/hr outweighs any risk.


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Hypokalaemia and hyperkalaemia Hypokalaemia and hyperkalaemia are potentially life-threatening conditions during the management ofDKA. There is a risk of acute pre-renal kidney injuryassociated with severe dehydration and it is thereforerecommended that no potassium be prescribed withthe initial fluid resuscitation or if the serum potassiumlevel remains above 5.5mmol/L. A normal or evenelevated serum potassium concentration may be seendue to the extracellular shift of potassium in acidoticconditions, and this very poorly reflects the patient'stotal potassium stores. However, potassium willalmost always fall as the DKA is treated with insulin.Thus it is recommended that 0.9% sodium chloridesolution with potassium 40mmol/L (ready-mixed) isprescribed as long as the serum potassium level isbelow 5.5mmol/L and the patient is passing urine. If the serum potassium level falls below 3.5mmol/Lthe potassium regimen needs review. Where the fluidbalance permits, an increase in the rate of theinfusion of 0.9% sodium chloride solution withpotassium 40mmol/L is possible. Otherwise, a moreconcentrated potassium infusion will be needed andto ensure safe practice, all aspects of its use mustcomply with local and national guidance 59,60.

Trusts need to ensure that they have local protocols inplace, which allow for the safe administration ofconcentrated potassium solutions. This may requiretransfer to a higher care environment. Electrolytemeasurements can be obtained from most modernblood gas analysers and should be used to regularlymonitor sodium, potassium and bicarbonate levels.

HypoglycaemiaThe blood glucose may fall very rapidly as ketoacidosisis corrected and a common mistake is to allow theblood glucose to drop to hypoglycaemic levels. This may result in a rebound ketosis driven bycounter-regulatory hormones. Rebound ketosislengthens duration of treatment.

Severe hypoglycaemia is also associated with cardiacarrhythmias, acute brain injury and death. Once theblood glucose falls to 14.0mmol/L, intravenous 10%

glucose needs to be commenced alongside the 0.9%sodium chloride solution to prevent hypoglycaemia.

Cerebral oedemaCerebral oedema causing symptoms is relativelyuncommon in adults during DKA althoughasymptomatic cerebral oedema may be a commonoccurrence 61. The observation that cerebral oedemausually occurs within a few hours of initiation oftreatment has led to the speculation that it isiatrogenic 62. However, this is disputed sincesubclinical cerebral oedema may be present beforetreatment is started 63. The exact cause of thisphenomenon is unknown; previous work in animalsand humans has suggested that cerebralhypoperfusion with subsequent reperfusion may bethe mechanism operating 54,64,65.

Cerebral oedema associated with DKA is morecommon in children than in adults. In the UK,previous data suggested that around 70 to 80% ofdiabetes-related deaths in children under 12 years ofage were as a result of cerebral oedema 66. The UKcase control study of cerebral oedema complicatingDKA showed that children who developed cerebraloedema were more acidotic and, after severity ofacidosis was corrected for, insulin administration inthe first hour and volume of fluid administered overthe first 4 hours were associated with increased risk 67.Retrospective evidence has shown increased risk forcerebral oedema after bicarbonate administration 53.

Pulmonary oedemaPulmonary oedema has only been rarely reported inDKA. As with cerebral oedema, the observation thatpulmonary oedema usually occurs within a few hoursof initiation of treatment has led to the speculationthat the complication is iatrogenic and that rapidinfusion of crystalloids over a short period of timeincreases the likelihood of this complication 68. Elderly patients and those with impaired cardiacfunction are at particular risk and appropriate non-invasive or invasive monitoring should be considered.

Serious complications of DKA andtheir treatment

DKA Pathway of care


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DKA is a medical emergency with a significantmorbidity and mortality. It should be diagnosedpromptly and managed intensively. The specialistdiabetes team should always be involved as soon aspossible and ideally within 24 hours because this hasbeen demonstrated to be associated with a betterpatient experience and reduced length of stay.

For young people under the age of 18 years,contact your paediatric diabetes service and usethe BSPED DKA guidelines which can be foundathttp://www.bsped.org.uk/clinical/docs/DKAGuideline.pdf

Assessment of severityThe presence of one or more of the following mayindicate severe DKA.

• Blood ketones over 6mmol/L

• Bicarbonate level below 5mmol/L

• Venous/arterial pH below 7.0

• Hypokalaemia on admission (under 3.5mmol/L)

• GCS less than 12 or abnormal AVPU scale

• Oxygen saturation below 92% on air (assumingnormal baseline respiratory function)

• Systolic BP below 90mmHg

• Pulse over 100 or below 60bpm

• Anion gap above 16 [Anion Gap = (Na+ + K+) –(Cl- + HCO3

-) ]

If the patient exhibits any of these signs they shouldbe reviewed by a consultant physician andconsidered for referral to a Level 2/HDU (HighDependency Unit) environment 69. It may also benecessary to consider a surgical cause for thedeterioration. If surgery is required there will need tobe an urgent senior multidisciplinary discussion onthe optimum time to operate.

Provision of careLocal care pathways should identify the units that areto care for DKA patients. Nursing staff appropriatelytrained in Level 2/HDU should take the lead in handson patient care.

New principlesThe insulin infusion rate is calculated by weight,which may need to be estimated. Administration byweight allows insulin resistant states to be at leastpartially accommodated. Reliance on standard VRIIIregimens will fail to accommodate for the very obeseor the pregnant patient and risks premature reductionof insulin dosage. Where blood ketonemeasurements are available the adequacy of theinsulin regimen is determined by the rate of fall of theketones and will need revision if this is inadequate. Ifbedside ketone measurement is not available, thevenous bicarbonate level can be used to assess theresponse to treatment during the first 6 hours, butmay be less reliable thereafter due to theconfounding influence of the high chloride levelsassociated with large volumes of 0.9% sodiumchloride solution. This is particularly important whenglucose levels are relatively normal. Supplementaryglucose solution may need to be infused at somestage in treatment to provide substrate. This willpermit the FRIII to be maintained, avoidhypoglycaemia and allow the full suppression ofketone production.

A. Hour 1: Immediatemanagement upon diagnosis: 0 to 60 minutes.T = 0 at time intravenous fluids are commenced.If there is a problem with intravenous access,critical care support should be requestedimmediately

Aims

• Commence IV 0.9% sodium chloride solution

• Commence a FRIII but only after fluid therapy hasbeen commenced

• Establish monitoring regime appropriate to patient;generally hourly blood glucose (BG) and hourlyketone measurement, with at least 2 hourly serumpotassium and bicarbonate for the first six hours

• Clinical and biochemical assessment of the patient

• Involve the diabetes specialist team at the earliestpossible stage

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Action 1 - Intravenous access and initialinvestigations• Rapid ABC (Airway, Breathing, Circulation)

• Large bore IV cannula (use ports to reduceinfection risk) and commence IV fluid replacement(See Action 2)

• Clinical assessment

• Respiratory rate; temperature; blood pressure;pulse; oxygen saturation

• Glasgow Coma Scale. NB: a drowsy patient in thecontext of DKA is serious and the patient requirescritical care input. Consider an NG tube withairway protection to prevent aspiration

• Full clinical examination

Initial investigations should include:

• Blood ketones

• Capillary blood glucose

• Venous plasma glucose

• Urea and electrolytes

• Venous blood gases

• Full blood count

• Blood cultures

• ECG

• Chest radiograph if clinically indicated

• Urinalysis and culture

• Continuous cardiac monitoring

• Continuous pulse oximetry

• Consider precipitating causes and treatappropriately

• Establish usual medication for diabetes

• Pregnancy test in women of child bearing age

Action 2 – Restoration of circulatingvolumeAssess the severity of dehydration using pulse andblood pressure. As a guide 90mmHg may be used asa measure of hydration but take age, gender andconcomitant medication into account.

Systolic BP (SBP) on admission below 90mmHg

Hypotension is likely to be due to low circulatingvolume, but consider other causes such as heartfailure, sepsis, etc.

• Give 500ml of 0.9% sodium chloride solution over10-15 minutes. If SBP remains below 90mmHg thismay be repeated whilst awaiting senior input.In practice most patients require between 500 to1000ml given rapidly.

• If there has been no clinical improvementreconsider other causes of hypotension and seekan immediate senior assessment. Considerinvolving the ITU/critical care team.

• Once SBP above 90mmHg follow fluidreplacement as shown below


Systolic BP on admission 90mmHg and over

Below is a table outlining a typical fluid replacement regimen for a previously well 70kg adult. This is anillustrative guide only. A slower infusion rate should be considered in young adults (see Controversial Areas).

Fluid Volume

0.9% sodium chloride 1L * 1000ml over 1st hour

0.9% sodium chloride 1L with potassium chloride 1000ml over next 2 hours





Re-assessment of cardiovascular status at 12 hours is mandatory, further fluid may berequired

*Potassium chloride may be required if more than 1 litre of sodium chloride has been given already to resuscitatehypotensive patients

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Exercise caution in the following patients

• Young people aged 18-25 years

• Elderly

• Pregnant

• Heart or kidney failure

• Other serious co-morbidities

In these situations admission to a Level 2/HDUfacility should be considered. Fluids should bereplaced cautiously, and if appropriate, guided bythe central venous pressure measurements.

Action 3 - Potassium replacementHypokalaemia and hyperkalaemia are lifethreatening conditions and are common in DKA.Serum potassium is often high on admission(although total body potassium is low) but fallsprecipitously upon treatment with insulin. Regular monitoring is mandatory.

Action 4 - Commence a fixed rateintravenous insulin infusion (FRIII) • If a weight is not available from the patient,

estimate it in kilograms

• If the patient is pregnant, use her present weightand call for immediate senior obstetric help aswell

• Start a continuous FRIII via an infusion pump.This is made of 50 units of human soluble insulin(Actrapid®, Humulin S®) made up to 50ml with0.9% sodium chloride solution. Ideally thisshould be provided as a ready-made infusion

• Infuse at a fixed rate of 0.1 unit/kg/hr (i.e. 7ml/hrif weight is 70kg) (See table on page 12)

• Only give a bolus (stat) dose of intramuscularinsulin (0.1 unit/kg) if there is a delay in settingup a FRIII

• If the patient normally takes Lantus®, Levemir®

or Tresiba® subcutaneously continue this at theusual dose and usual time (although the optionexists to continue human basal insulin as well)

• Insulin may be infused in the same line as theintravenous replacement fluid provided that a Yconnector with a one way, anti-siphon valve isused and a large-bore cannula has been placed

B. 60 minutes to 6 hoursAims:• Clear the blood of ketones and suppress

ketogenesis

• Achieve a rate of fall of ketones of at least0.5mmol/L/hr

• In the absence of ketone measurement,bicarbonate should rise by 3.0mmol/L/hr andblood glucose should fall by 3.0mmol/L/hr

• Maintain serum potassium in the normal range

• Avoid hypoglycaemia

Action 1 – Re-assess patient, monitorvital signs• During this time, patients should be reviewed

hourly initially to ensure that adequate progressis being made in reducing the ketone and/orglucose concentrations

• Consider urinary catheterisation if the patient isincontinent or anuric (i.e. not passed urine by 60minutes)

• Consider naso-gastric tube insertion if thepatient is obtunded or persistently vomiting

• If the oxygen saturation falls, then perform anarterial blood gas measurement and request arepeat chest radiograph


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Potassium level in first 24 hours Potassium replacement in mmol /L of infusion solution(mmol/L)

Over 5.5 Nil

3.5-5.5 40

Below 3.5 Senior review as additional potassium needs to be given (see serious complications section)


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• Regular observations and Early Warning Score(EWS) charting as appropriate

• Maintain an accurate fluid balance chart, theminimum urine output should be no less than0.5ml/kg/hr

• Continuous cardiac monitoring in those withsevere DKA

• Give low molecular weight heparin as per NICEguidance 70

Action 2 – Review metabolicparameters• Measure blood ketones and capillary glucose

hourly (note: if meter reads “blood glucose over20mmol/L" or “Hi” venous blood should be sentto the laboratory hourly or measured usingvenous blood in a blood gas analyser until thebedside meter is within its QA range)

• Review patient’s response to FRIII hourly bycalculating the rate of change of ketone levelfall (or rise in bicarbonate or fall in glucose).

• Assess the resolution of ketoacidosis

o If blood ketone measurement isavailable and blood ketones are notfalling by at least 0.5mmol/L/hr call aprescribing clinician to increase theinsulin infusion rate by 1.0 unit/hrincrements hourly until the ketones arefalling at target rates (also checkinfusion**)

o If blood ketone measurement is notavailable, use venous bicarbonate. If thebicarbonate is not rising by at least3.0mmol/L/hr call a prescribing clinicianto increase the insulin infusion rate by 1unit/hr increments hourly until thebicarbonate is rising at this rate**

o Alternatively use plasma glucose. If theglucose is not falling by at least3.0mmol/L/hr call a prescribing clinicianto increase the insulin infusion rate by1.0 unit/hr increments hourly untilglucose falls at this rate. Glucose level isnot an accurate indicator of resolutionof acidosis in euglycaemic ketoacidosis,so the acidosis resolution should beverified by venous gas analysis**

** If ketones and glucose are not falling asexpected always check the insulin infusionpump is working and connected and that thecorrect insulin residual volume is present (tocheck for pump malfunction)

• Measure venous blood gas for pH, bicarbonateand potassium at 60 minutes, 2 hours and 2hourly thereafter

• If the potassium is outside the reference range,assess the appropriateness of the potassiumreplacement and check it hourly. If it remainsabnormal after a further hour, seek immediatesenior medical advice (see Action 3 p20)

• Continue the FRIII until the ketone measurementis less than 0.6mmol/L, venous pH over 7.3and/or venous bicarbonate over 18mmol/L (see section C)

• Do not rely on urinary ketone clearance toindicate resolution of DKA, because these willstill be present when the DKA has resolved

• If the glucose falls below 14.0mmol/L,commence 10% glucose given at 125ml/houralongside the 0.9% sodium chloride solution

• Monitor and replace potassium because it mayfall rapidly

Action 3 – Identify and treatprecipitating factors

Action 4 Patients presenting with newly diagnosed type 1diabetes should be given Lantus® or Levemir® (orhuman NPH insulin, depending on local policy) at adose of 0.25 units/Kg subcutaneously once daily tomitigate against rebound ketosis when they aretaken off the FRIII 49.

C. 6 to 12 hours.Aim:

The aim within this time period is to:

• Ensure that clinical and biochemical parametersare improving

• Continue IV fluid replacement

• Continue insulin administration

• Assess for complications of treatment e.g. fluidoverload, cerebral oedema

• Continue to treat precipitating factors asnecessary

• Avoid hypoglycaemia

Action 1 – Re-assess patient, monitorvital signs• If the patient is not improving then seek senior

advice

• Ensure a referral has been made to the specialistdiabetes team

Action 2 – Review biochemical andmetabolic parameters• At 6 hours check the venous pH, bicarbonate,

potassium, as well as blood ketones and glucose

• Resolution of DKA is defined as ketones lessthan 0.6mmol/L and venous pH over 7.3 (do notuse bicarbonate as a surrogate at this stagebecause the hyperchloraemic acidosis associatedwith large volumes of 0.9% sodium chloride willlower bicarbonate levels)

If DKA resolved go to section E.

If DKA not resolved refer to Action 2 inSection B.

D. 12 to 24 HOURSExpectation:

By 24 hours the ketonaemia and acidosis shouldhave resolved

Aim:• Ensure that the clinical and biochemical

parameters are improving or have normalised

• Continue IV fluids if the patient is not eatingand drinking

• If the patient is not eating and drinking andthere is no ketonaemia move to a VRIII as perlocal guidelines

• Re-assess for complications of treatment e.g.fluid overload, cerebral oedema

• Continue to treat any precipitating factors asnecessary

• Transfer to subcutaneous insulin if the patient iseating and drinking normally. Ensure that thesubcutaneous insulin is started before the IVinsulin is discontinued. Ideally give thesubcutaneous fast acting insulin at a meal anddiscontinue IV insulin one hour later

Action 1 – Re-assess patient, monitorvital signs

Action 2 – Review biochemical andmetabolic parameters• At 12 hours check venous pH, bicarbonate,

potassium, as well as blood ketones and glucose

• Resolution of DKA is defined as ketones lessthan 0.6mmol/L, and venous pH over 7.3

If DKA resolved go to section E.

If DKA not resolved refer to Action 2 inSection B and seek senior specialist advice asa matter of urgency.

Expectation: Patients should be eating anddrinking and back on normal insulin. If thisexpectation is not met within this time period it isimportant to identify and treat the reasons for thefailure to respond to treatment. It is unusual forDKA not to have resolved by 24 hours withappropriate treatment and requires senior andspecialist input.

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NB: Do not rely on bicarbonate alone to assessthe resolution of DKA at this point due to thepossible hyperchloraemia secondary to highvolumes of 0.9% sodium chloride solution. The hyperchloraemic acidosis will lower thebicarbonate and thus lead to difficulty isassessing whether the ketosis has resolved. The hyperchloraemic acidosis may cause renalvasoconstriction and be a cause of oliguria.


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E. Conversion to subcutaneousinsulin

The patient should be converted to an appropriatesubcutaneous regime when biochemically stable(blood ketones less than 0.6mmol/L, pH over 7.3)and the patient is ready and able to eat.Conversion to subcutaneous insulin is ideallymanaged by the diabetes specialist team. If theteam is not available see Appendix 1. If the patientis newly diagnosed, it is essential they are seen bya member of the specialist team prior to discharge.

Specialist diabetes team inputIn line with the Best Practice Tariff, if they are notalready involved, the local diabetes team should beinformed and the patient reviewed within 24 hoursof admission 32. Specialist diabetes team input isimportant to allow re-education, to reduce thechance of recurrence, and to facilitate appropriatefollow up.

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Implementation of the guidelines

Repeated audits by many diabetes units in allconstituent UK countries have consistentlydemonstrated poor adherence to local (or national)guidelines in the management of DKA. There aretwo main problems to be addressed:

1) The guidelines must be implemented

2) The guidelines must be audited

The guidelines must be reviewed regularly: The next planned review is 2016.

Commissioning of careDiabetic Ketoacidosis is a recognised commonmedical emergency and must be treatedappropriately. For this to occur, the HealthEconomies within the United Kingdom mustaddress management of DKA in the context ofprovision of expert medical and nursing inputwithin secondary care. In the majority of casespeople with type 1 diabetes should be underspecialist care. Commissioners, Primary CareProviders, Local Diabetes Networks and DiabetesDirectorates within the Acute Trusts, should co-operate and ensure the Quality Indicators andAudit Standards set out below are met.

Audit

Quality indicatorsEvery Acute Trust should have a local managementplan in place based upon these, or otherauthoritative guidelines. Guidelines must becurrent and valid and should not be used if thereview date has expired. If there is no review date,they should not be used.

Every Acute Trust should have nominated careareas for patients with diabetic ketoacidosis.

Every Acute Trust should have trained Health CareWorkers available to measure blood ketone levels24 hours per day.

Every Acute Trust should have a Quality AssuranceScheme in place to ensure accuracy of bloodglucose and ketone meters.

People admitted to hospital with diabeticketoacidosis receive educational and psychologicalsupport prior to discharge and are followed up bya diabetes specialist team (NICE CG15).

We recommend that every Acute Trust useperformance indicators to assess the quality of caregiven (examples given in Appendix 2). A TreatmentPathway document may be beneficial, asadherence to guidelines for this condition is verypoor and integrated pathway documents (anexample of which is given online) would improvecompliance.


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Restarting subcutaneous insulin for patientsalready established on insulin

The patient’s previous regimen should generally bere-started if their most recent HbA1c suggestsacceptable level of control i.e. HbA1c 64mmol/mol(<8.0%)

With all regimens the intravenous insulin infusionshould not be discontinued for at least 30 to 60minutes after the administration of the subcutaneousdose given in association with a meal.

If the patient was on basal bolus insulin

• There should be an overlap between the insulininfusion and first injection of fast acting insulin.The fast acting insulin should be injected with themeal and the intravenous insulin and fluidsdiscontinued 30 to 60 minutes later

• If the patient was previously on a long actinginsulin analogue such as Lantus®, Levemir®, orTresiba® this should have been continued and thusthe only action should be to restart their normalshort acting insulin at the next meal

• If the basal insulin had been stopped in error, theinsulin infusion should not be stopped until someform of background insulin has been given. If thebasal analogue was normally taken once daily inthe evening and the intention is to convert tosubcutaneous insulin in the morning, give half theusual daily dose of basal insulin as isophane(Insulatard®, Humulin I®, Insuman basal®) in themorning, This will provide essential backgroundinsulin until the long acting analogue can berecommenced. Check the blood ketone andglucose levels regularly

If the patient was on twice daily fixed-mix insulin

• Re-introduce the subcutaneous insulin beforebreakfast or before the evening meal. Do notchange at any other time. Maintain the insulininfusion until 30 to 60 minutes after thesubcutaneous insulin was given

If the patient was on CSII

• Recommence the CSII at the normal basal rate.Continue intravenous insulin infusion until themeal bolus has been given. Do not recommenceCSII at bedtime

Calculating the subcutaneous insulindose in insulin-naïve patientsEstimate Total Daily Dose (TDD) of insulin

This estimate is based on several factors, includingthe patient's sensitivity to insulin, degree of glycaemiccontrol, insulin resistance, weight, and age. The TDDcan be calculated by multiplying the patient's weight(in kg) by 0.5 to 0.75 units. Use 0.75 units/kg forthose thought to be more insulin resistant i.e. teens,obese.

Example: a 72kg person would requireapproximately 72 x 0.5 units or 36 units in 24 hours

Calculating a Basal Bolus (QDS)Regimen:Give 50% of total dose with the evening meal in theform of long acting insulin and divide remaining doseequally between pre-breakfast, pre-lunch and pre-evening meal.

Appendix 1

24

25

Pre-breakfast Pre-lunch Pre-evening meal Bedtime

Rapid acting insulin, 6 units 6 units 6 unitse.g Apidra®/Humalog®/NovoRapid®

Long acting insulin, 18 unitse.g. Lantus®/Levemir®

Administer the first dose of fast actingsubcutaneous insulin preferably prior to breakfastor lunch. Only administer the first dose before theevening meal if appropriate monitoring can beguaranteed. Do not convert to a subcutaneousregimen at bed time.

In patients new to insulin therapy doserequirements may decrease within a few daysbecause the insulin resistance associated with DKAresolves. Close supervision from the diabetesspecialist team is required.

Calculating a twice daily (BD) regimen:If a twice daily pre-mixed insulin regimen is to beused, give two thirds of the total daily dose atbreakfast, with the remaining third given with theevening meal.


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Appendix 2


Audit standards for the managementof the adult patient with diabeticketoacidosisPurpose of these audit standards

• Maximise patient safety and quality of care

• Support professional best practice

• Deliver enhanced patient satisfaction

• Reduce Trust operating costs (litigation,complaint procedures)

• Contribute to improved financial performance(reduced length of stay)

Institutional Standards:

Indicator Standard

Access:

Institutional Accountability and Integrity:

NPSA Standards 71,72

Has the Trust either adopted these NationalGuidelines or has their own alternative,evidence based and audited internal guidelinesfor the management of the adult patientadmitted with diabetic ketoacidosis?

Yes

Does the Trust collect data about the outcomes forpatients admitted with diabetic ketoacidosis?

Yes

Does the Trust have the services of a dedicatedDiabetes Inpatient Specialist Nurse (DISN) atstaffing levels most recently recommended byDiabetes UK (1.0 WTE per 300 beds)?

Yes

Does the Trust have a ‘clinical lead’ for themanagement of the adult patient admitted withdiabetic ketoacidosis with responsibility forimplementation of the DKA guidelines?

Yes

All regular and single insulin (bolus) doses aremeasured and administered using an insulinsyringe or commercial insulin pen device.Intravenous syringes must never be used forinsulin administration.

100%

The term ‘units’ is used in all contexts.Abbreviations, such as ‘U’ or ‘IU’, are never used 100%

All clinical areas and community staff treatingpatients with insulin have adequate supplies ofinsulin syringes and subcutaneous needles, whichstaff can obtain at all times.

100%

An insulin syringe must always be used tomeasure and prepare insulin for an intravenousinfusion.

100%


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A training programme should be put in placefor all healthcare staff (including medical staff)expected to prescribe, prepare and administerinsulin (e.g. the safe use of insulin and the safeuse of intravenous insulin e-learning packagesfrom NHS Improving Quality).

100%

Policies and procedures for the preparation andadministration of insulin and insulin infusions inclinical areas are reviewed to ensure compliancewith the above.

100%

Death or severe harm as a result ofmaladministration of insulin by a healthprofessional.

Never

Department of Health ‘Never Event’ Standard 73

People admitted to hospital with diabeticketoacidosis should be referred to the diabetesspecialist team on admission.

100%

Additional Best Practice Tariff Standards 32:

People admitted to hospital with diabeticketoacidosis should be seen by member of thediabetes specialist team within 1 working day ofadmission.

100%

People with diabetes should have access to thediabetes specialist team. 100%

Where clinically appropriate, people withdiabetes should have the choice to self monitortheir condition.

80%

People admitted to hospital with diabeticketoacidosis receive educational support from amember of the diabetes specialist team prior todischarge. This education should include

• Review of usual glycaemic control

• Review of injection technique/blood glucosemonitoring/equipment/sites

• Discussion of sick day rules

• Assessment of the need for home ketonetesting (blood or urinary) with education toenable this

• Provision of contact telephone numbers forthe diabetes specialist team including out ofhours

100%

Patients are seen by a diabetologist or DISNprior to discharge. 100%


People admitted to hospital with diabeticketoacidosis receive psychological support froma member of the diabetes specialist team priorto discharge.

75%

People admitted to hospital with diabeticketoacidosis receive follow up by a diabetesspecialist team.

100%

People admitted to hospital with diabeticketoacidosis should be discharged with awritten care plan: a process that allows theperson with diabetes to have active involvementin deciding, agreeing and owning how theirdiabetes is managed. This should be copied tothe GP.

100%

Percentage of patients where their discharge isdelayed because of diabetes related problems.

0%

Access to structured education offered withinthree months.

100%

Percentage of patients with diabetes identifiedas such on hospital patient administrationsystem.

95%

Percentage of clinical coding that identifiespeople with diabetes correctly.

100%

Percentage of staff who feel that they havesufficient levels of appropriate and timelysupport from the Diabetes Inpatient SpecialistTeam.

100%

Percentage of patients who express satisfactionwith their patient journey, using validated toolssuch as the Diabetes Treatment SatisfactionQuestionnaire (DTSQ) and the DiabetesTreatment Satisfaction Questionnaire forInpatients (DTSQ-IP).

80%

Institutional Accountability and Integrity:

Patient and Staff Satisfaction:

29

These guidelines have been developed to advisethe treatment and management of diabeticketoacidosis in adults.

The guideline recommendations have beendeveloped and reviewed by a multidisciplinaryteam led by the Joint British Diabetes Society(JBDS) and including representation from DiabetesUK. People with diabetes have been involved in thedevelopment of the guidelines via stakeholderevents organised by Diabetes UK.

It is intended that the guideline will be useful toclinicians and service commissioners in planning,organising and delivering high quality diabetes

inpatient care. There remains, however, anindividual responsibility of healthcare professionalsto make decisions appropriate to the circumstanceof the individual patient, informed by the patientand/or their guardian or carer and taking fullaccount of their medical condition and treatment.

When implementing this guideline full accountshould be taken of the local context and in linewith statutory obligations required of theorganisation and individual. No part of theguideline should be interpreted in a way thatwould knowingly put people, patient or clinician at risk.

Statement for inpatient guidelines


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Documents

Joint British Diabetes Societies Inpatient Care Group British Diabetes Societies Inpatient Care Group ... org.uk Diabetic ketoacidosis (DKA), ... version of this document at