CLINICAL GUIDELINE FOR THE MANAGEMENT OF DIABETIC KETOACIDOSIS (DKA) IN ADULTS 1. Aim/Purpose of this Guideline This guideline is for the management of Adult patients with Diabetes Mellitus during Diabetic Ketoacidosis. It has been benchmarked against national guidance, to provide detailed guidance on the clinical management of Diabetes during DKA in line with best practice guidelines. 2. The Guidance (or affix label) Patient Name ------------------------------- Date Started -------------------Date of Birth ------------------------------- Ward ----------------------------- GUIDELINE FOR THE MANAGEMENT OF DIABETIC KETOACIDOSIS (DKA) IN ADULTS Definition Severe uncontrolled known diabetes or new presentation Blood Glucose > 11mmol/l Bicarbonate (HCO3) < 15 mmol/l and /or venous PH < 7.3 The Presence of one or more of the following may indicate severe DKA and require admission to the critical care unit Pregnancy, Bicarbonate < 5 mmol/l, Venous pH < 7.1, Hypokalaemia on admission <3.5 mmol/l GCS < 12, Oxygen saturation < 92 %, Systolic BP below 90 mmHg, Pulse < 60 or > 100 bpm Anion Gap > 16 Page 1 of 10 Tick boxes when task completed Step 1: 0 - 60 MIN IMMEDIATE MANAGEMENT FLUID REPLACEMENT - IV Cannula - Start 0.9% Sodium Chloride 1000ml/hour (All fluids / potassium and insulin must be prescribed on the main prescription chart) INITIAL INVESTIGATIONS - U&Es, HCO3 and Anion gap - Plasma Blood Glucose - Venous pH - Fluid balance - Urine ketones START INSULIN - Soluble 6 units/hour IV - Continue Long Acting Analogue Insulin i.e. Lantus / Levemir OTHER INTERVENTIONS - Document Glasgow Coma Scale - Consider central line - Consider cardiac monitoring - Nasogastric tube if vomiting or airway unprotected - Discontinue insulin pump if insulin pump patient - Inform Diabetes Specialist Nurse Mon – Fri bleep 2205 / #3104 - Inform Endocrine F1 Mon – Fri 9am – 5 pm - Inform Endocrine ward and site team SUPPLEMENTARY NOTES Typical Fluid replacement regimen Fluid Volume 0.9% Sodium chloride 1L 0.9% Sodium chloride 1L with KCL 0.9% Sodium chloride 1L with KCL 0.9% Sodium chloride 1L with KCL 0.9% Sodium chloride 1L with KCL 0.9% Sodium chloride 1L with KCL 1000ml over 1 hr 1000 ml over next 2 hrs 1000 ml over next 2 hrs 1000 ml over next 4 hrs 1000 ml over next 4 hrs 1000 ml over next 6 hrs START INSULIN Use soluble insulin e.g. Actrapid or Humulin S - Concentration should be 50 units of insulin made up to 50mls of normal saline administered through a syringe pump. - Insulin should be prescribed on the regular section of the main prescription chart. - Fluids, insulin and potassium must be prescribed on the main prescription chart - Insulin may be infused in the same line as the intravenous replacement fluid provided that a Y connector with a one way anti-syphon valve is used and a large-bore cannula has been placed MEWS Record MEWS as per hospital policy and report mews score of moderate or high to Doctor / Senior nurse for review, and maintain observations as per MEWS risk assessment POTASSIUM Potassium Replacement – 40mmols/KCL must be in 1 litre of fluid. Under no circumstances should KCl be administered at a rate greater than 20 mmol/hour unless facilities for intensive monitoring are available INFORM STAFF Will require an Endocrine bed in 8 – 10 hours Page 2 of 10 Tick boxes when task completed SUPPLEMENTARY NOTES BIOCHEMICAL AND CLINCIAL MONITORING Step 2: Hours 60 mins – 6 hours ON GOING MANAGEMENT Blood Glucose Monitoring / Recording BIOCHEMICAL and CLINICAL MONITORING 60 mins Hour 2 Hour 4 Hour 6 - U&Es / Anion gap / bicarb - Venous pH - Document GCS - Hourly Blood Glucose 60 mins Hour 1 Hour 2 Hour 3 Hour 4 Hour 5 Hour 6 FLUID and ELECTROLYTES BICARBONATE FLUID and ELECTROLYTES Potassium Replacement – 40mmols/KCL must be in 1 litre of fluid. Under no circumstances should KCl be administered at a rate greater than 20 mmol/hour unless facilities for intensive monitoring are available - Use potassium containing fluids unless anuric + 40mmols/L if serum K < 3.5 – 5 mmol/l INSULIN and DEXTROSE INSULIN and DEXTROSE Blood glucose can return to normal before ketones are removed from the blood. Continue with intravenous insulin at 3 or 6 units until pH > 7.3 and bicarbonate > 12 mmol/L, unless patient deteriorates - Infuse insulin at 6 units/hr if blood glucose is falling at less than 5 mmol/L/hr, - Reduce insulin infusion to 3 units/hr if blood glucose is falling at more than 5 mmol/L/hr Hour 2 Record blood glucose on the CHA 2306 Diabetic Monitoring and Sliding Scale chart. Ensure that the sliding scale insulin prescription is crossed through and not used If the bicarbonate is not rising by at least 3 mmol/L gain senior medical review - Continue with 0.9% Sodium Chloride according to patient’s volume requirements 60 mins Measure capillary blood glucose hourly If meter reads “blood glucose > 20 mmol/L or HI” venous blood should be sent to the laboratory hourly or measured in a blood glucose analyser until the bedside meter is within its QA range Hour 4 Hour 6 Ensure that long acting insulin has been continued and prescribed on the main prescription chart Insulin rate checked - Infuse 10% dextrose at 100ml/hour if blood glucose <14 mmol/L at 125 ml/hr along side 0.9% sodium chloride - Continue Long Acting Analogue Insulin i.e. Lantus / Levemir Insulin may be infused in the same line as the intravenous replacement fluid provided that a Y connector with a one way anti-syphon valve is used and a large-bore cannula has been placed (All fluids / potassium and insulin must be prescribed on the main prescription chart) OTHER INVESTIGATIONS AS INDICATED - Chest X Ray - ECG - MSU - Blood cultures - Viral titres - Full blood count - Urinary catheter if diuresis has not occurred MEWS Record MEWS as per hospital policy and report mews score of moderate or high to Doctor / Senior nurse for review, and maintain observations as per MEWS risk assessment CEREBRAL OEDEMA Children (refer to paediatric guideline) and adolescents are at the highest risk, which may be increased if blood glucose falls at rates of > 5mmolL per hour. Presentation is with headache or declining GCS in a patient who is otherwise biochemically improving. If cerebral oedema is suspected refer to critical care Page 3 of 10 Tick boxes when task completed Step 3: Hour 6 SUPPLEMENTARY NOTES ON GOING MANAGEMENT ON GOING MANAGEMENT BIOCHEMICAL and CLINICAL MONITORING The aim is to: - ensure that clinical and biochemical parameters are improving - Review U&Es / Anion gap / bicarb - Review Venous pH - Document GCS - continue IV fluid replacement - continue insulin administration - assess for complications of treatment If DKA resolved , pH > 7.3, bicarbonate > 12 mmolL go to Step - continue to treat precipitating factors 4 If DKA not resolved return to Step - avoid hypoglycaemia 2 DSN and DSN to inform Endocrine team if patient requires prolonged stay in Level 2 care setting seek senior specialist advise as a matter of urgency Step 4: Hours 6 – 24 DISCHARGE PLAN - after 8 hours if no signs of sepsis or other SPECIALIST REVIEW remaining medical precipitant of DKA pt can move out of a level 2 care setting - If the patient is not eating and drinking and there is no ketonuria change to a variable rate insulin infusion (standard sliding scale insulin infusion) - If the patient is eating and drinking convert back to an appropriate subcutaneous insulin regimen. Ensure that the long acting insulin has been continued and administered prior to discontinuing the intravenous insulin infusion at a meal time. (if not see below) Recommence long acting insulin if not continued as per steps 1 / 2 at least 6 hours prior to discontinuing the intravenous insulin infusion at a meal time (see SSI CHA 2306 sliding scale chart for guidance) - Transfer to endocrine ward To determine cause of episode and review diabetes education Refer as indicated to - Diabetes Specialist Nurse - Endocrinologist DISCHARGE ONLY WHEN - Biochemically stable - Eating and drinking - Established on subcutaneous insulin regimen FOLLOW UP - Diabetes Specialist Nurse - Outpatient Endocrinologist appointment arranged - Copy of the discharge letter to the diabetes team Page 4 of 10 3. Monitoring compliance and effectiveness Element to be monitored Lead All of It Specialist Adult In-Patient Diabetes Team Tool Patient Documentation Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Adult in-patients with diabetes who are diagnosed with DKA and who are reviewed by the specialist diabetes team Non compliance will be reported to the responsible medical team, ward /area manager. Non compliance resulting in an adverse patient event will be reported via Datix Medical teams / ward / area managers will undertake subsequent recommendations and action planning for any or all deficiencies and recommendations within reasonable timeframes for their areas The Specialist Adult In-Patient Diabetes Team will undertake any trust wide recommendations and action planning for any or all deficiencies and recommendations within reasonable timeframes Lesson learned or changes to practice will be shared with all the relevant stakeholders 4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement. 4.2. Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2. Page 5 of 10 Appendix 1. Summary Guideline for the Management of Diabetic Ketoacidosis (DKA) in Adults Summary guidance published separately – available via Document Library (search for Diabetic Ketoacidosis or DKA or click here) Page 6 of 10 Appendix 2. Governance Information Document Title CLINICAL GUIDELINE FOR THE MANAGEMENT OF DIABETIC KETOACIDOSIS (DKA) IN ADULTS Date Issued/Approved: 15-02-13 Date Valid From: 15-02-13 Date for Review: January 2016 Directorate / Department responsible (author/owner): Medical Directorate Amanda Veall Clinical Nurse Specialist Diabetes Contact details: 01872 253104 Brief summary of contents Guideline for the Management of Diabetic Ketoacidosis in Adults Suggested Keywords: Diabetes, Diabetic Ketoacidosis RCHT Target Audience PCT CFT Executive Director responsible for Policy: Medical Director Governance Date revised: January 2013 This document replaces (exact title of previous version): Guideline For The Management Of Diabetic Ketoacidosis In Adults 2010 Consultant Endocrinologists, Diabetes InPatient Specialist Nurses, Consultant Anaesthetist, Emergency Medicine Consultant, Medical Admission Consultant Approval route (names of committees)/consultation: Divisional Manager confirming approval processes Rowena Green Name and Post Title of additional signatories Not Required Signature of Executive Director giving approval Publication Location (refer to Policy on Policies – Approvals and Ratification): {Original Copy Signed} Internet & Intranet Intranet Only Document Library Folder/Sub Folder Diabetes Quick Reference Guide Links to key external standards NSF for Diabetes 2001 Related Documents: NHS DIABETES 2010 Joint British Diabetes Societies Inpatient Page 7 of 10 Care Group The Management of Diabetic Ketoacidosis in Adults Yes - Learning and Development department have been informed. Training Need Identified? Version Control Table Date Versio n No Summary of Changes Jan 2012 V1 Initial Issue Jan 2013 V2 Updated to reflect the National Guidance, including venous PH Changes Made by (Name and Job Title) Amanda Veall Clinical Nurse Specialist Diabetes Amanda Veall Clinical Nurse Specialist Diabetes All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager. Page 8 of 10 Appendix 3.Initial Equality Impact Assessment Screening Form Name of service, strategy, policy or project (hereafter referred to as policy) to be assessed: Clinical Guideline For The Management Of Diabetic Ketoacidosis (Dka) In Adults Directorate and service area: Medical Is this a new or existing Procedure? Existing Directorate Name of individual completing Telephone:01872 253104 assessment: Amanda Veall 1. Policy Aim* To provide detailed guidance on the clinical management of Adults with Diabetes diagnosed with Diabetic Ketoacidosis 2. Policy Objectives* • To provide a consistent approach to the management of Diabetes within RCH sites. • To maintain patient safety and improve outcomes for adult patients with diagnosed with Diabetic Ketoacidosis in RCH sites 3. Policy – intended • Consistent management of Diabetes at RCH sites. Outcomes* • Prompt and safe management of Diabetic Ketoacidosis 5. How will you Audit measure the outcome? Datix Reporting Review of medical / nursing documentation as required 5. Who is intended to All adult patients with Diabetic Ketoacidosis within all RCH benefit from the Policy? sites 6a. Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? Yes b. If yes, have these groups been consulted? Yes c. Please list any groups Consultant Endocrinologists, Diabetes In-Patient Specialist Nurses, who have been consulted Consultant Anaesthetist, Emergency Medicine Consultant, Medical Admission Consultant about this procedure. *Please see Glossary 7. The Impact Please complete the following table using ticks. You should refer to the EA guidance notes for areas of possible impact and also the Glossary if needed. • • Where you think that the policy could have a positive impact on any of the equality group(s) like promoting equality and equal opportunities or improving relations within equality groups, tick the ‘Positive impact’ box. Where you think that the policy could have a negative impact on any of the equality group(s) i.e. it could disadvantage them, tick the ‘Negative impact’ box. Page 9 of 10 • Where you think that the policy has no impact on any of the equality group(s) listed below i.e. it has no effect currently on equality groups, tick the ‘No impact’ box. Equality Group Age Positive Impact Negative Impact No Impact x Disability x Religion or belief x Gender x Transgender x Pregnancy/ Maternity Race x Sexual Orientation x Marriage / Civil Partnership x Reasons for decision x You will need to continue to a full Equality Impact Assessment if the following have been highlighted: • A negative impact and • No consultation (this excludes any policies which have been identified as not requiring consultation). 8. If there is no evidence that the policy promotes equality, equal opportunities or improved relations - could it be adapted so that it does? How? Full statement of commitment to policy of equal opportunities is included in the policy Please sign and date this form. Keep one copy and send a copy to Matron, Equality, Diversity and Human Rights, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Chyvean House, Penventinnie Lane, Truro, Cornwall, TR1 3LJ A summary of the results will be published on the Trust’s web site. Signed __________Amanda Veall______________________________ Date _________23-01-2013________________________________ Page 10 of 10