Diabetic Ketoacidosis management update

1. Diabetic Ketoacidosis
A sweet new approach to an old problem

2. Outline
 DKA background
 The new protocol
 Approaches in other hospitals

3. What is it?
•
Hyperglycaemia
•
Ketosis and acidosis
•
Dehydration
•
Electrolyte imbalance

4. Hyperglycaemia
 DKA is a state of insulin deficiency
 It is also a state of relative excess of glucagon and other
hyperglycaemic hormones: catecholamines, cortisol, growth
hormone etc
 This is likely to be triggered by conditions that result in one of these
hormones being elevated
 Infection
 Pregnancy
 Medications (prescribed or non-prescribed)
 Trauma
 Burns

5. Ketosis and acidosis
 Due to enhanced gluconeogenesis there is significant
lipolysis
 Free fatty acids are metabolised into ketone bodies
(acetoacetate and beta hydroxybutyrate) which accumulate
 Ketone bodies dissociate into ketone anions and hydrogen
 The bodies buffering capacity is exhausted leading to excess
hydrogen ions

6. Dehydration
•
Osmotic diuresis
•
Vomiting
•
Third space

7. Electrolyte imbalance
 Potassium
 One third will have K >5.5
 All are potassium deplete (~300-600meq)
 Osmotic diuresis
 Sodium
 Increased osmolality dilutes extracellular sodium
 Osmotic diuresis causes increased extracellular sodium
 Phosphate
 Most will develop phosphate depletion but ?importance of this

8. The context
•
No hospital wide policy on DKA
•
Unclear DKA proforma
•
Ward to ward variations in
practise

9. The new model
 Standardised diagnosis
 Check for high risk criteria
 Standard fluid orders
 Fixed rate insulin dosing
 Maintain basal dose insulin

10. Why the change?
 Wide variability makes assessment of outcomes difficult
 Cerebral oedema in children +/- young adults
 Pulmonary oedema
 Hypo/hyperkalaemia
 Hypoglycaemia

11. Standardised diagnosis
 Fingerprick BSL and ketones
 Venous pH/gas unless hypoxic and/or ABG required
 Less emphasis on urine ketones

12. High risk criteria
 Any of the following should prompt early senior input and
NOSA/ICU review
 Ketones >6
 Bicarbonate <10
 pH < 7.1
 SpO2 <92%
 GCS <15
 SBP <90
 Pulse <60 or >100

13. Standard fluid orders
 Normal saline over 1, 2, 3, 4, 5, 6 hours
 Add 40mmol KCl to second and subsequent bags with K <5.5

14. Fixed rate insulin + basal
 No sliding scale until ketoacidosis resolved
 0.1units/kg/hr of actrapid in standard concentration
 Don’t switch it off until you switch it off!
 Continue basal insulin regime (lantus/protophane/levemir)
and consider basal pump function
 As previously, restart usual SC dosing then switch off infusion
30 min later.

16. Example cases

17. Mr JL
 63yo M
 pH 7.19, pCO2 26, HCO3 9
 T1DM since age 14, nil prior
 Na 133, K 5.9, Creat 185
DKA, usually on pump
 Widely metastatic colorectal
cancer on informal trial
chemotherapy
 Recent chesty cough
 Priority one with reduced
conscious state
 HR 100, BP 80/-, SpO2 90%
NRBM, T38.2, BSL 35
 Fingerprick ketone 6.0

18.  Ketones >6
 Bicarb <10
 pH <7.1
 GCS <15
 SBP <90
 Pulse >100 or <60
Patient severely unwell so
standard protocol does not
apply
However, don’t throw out the
whole idea of the protocol

19. Changes to protocol
 Patient likely to require HDU bed
and early review by inpatient team
 Continous monitoring
 Strict fluid balance chart
 More liberal initial fluid
resuscitation
 More regular blood testing
 BUT
 Fixed dose insulin
 Ongoing fingerprick ketone
measurement

20. Mr JG
 30yo M
 pH 7.28, pCO2 37, HCO3 17
 T1DM since childhood
 Na 139, K 4.0, Creat 60
 Polysubstance abuse
 BSL 25
 Priority 3 with abdominal
 Ketones 4
pain
 Obs normal

21.  Ketones >6
 Bicarb <10
 pH <7.1
 GCS <15
 SBP <90
 Pulse >100 or <60
Patient has mild DKA with no
high risk features, therefore
suitable for standard protocol

22. Useful resources
 Joint British Diabetes Societies guideline for the
management of diabetic ketoacidosis (2011), Diabetic
Medicine 28: 508-515

23. Questions?