Unc pediatric dka guidelines this is a general guideline and does not represent a professional care standard governing providers obligations to patients. Diabetic ketoacidosis dka management algorithm adult. Management of diabetic ketoacidosis in adults age 16 years. Emergency treatment should be sought if symptoms of dka occur, including abdominal pain, nausea, vomiting, fatigue, malaise, andor dyspnea. Dka accounts for more than 150,000 hospital admissions per year in the. British society of paediatric endocrinology and diabetes bsped guidelines for. Diabetes canada clinical practice guidelines expert committee. Diabetic ketoacidosis dka critical care guideline two. This is a quality improvement document and should not be part of the patients medical record. The protocol for the management of patients with dka is presented in figure 1. Diabetic ketoacidosis dka critical care guideline two bag.
Dka is the leading cause of death in children with type 1 diabetes 1, 2 and accounts for a significant proportion of admissions in adult patients with type 1 or type 2 diabetes 1, 3. Whatyoushouldknow diabeticketoacidosis dkaisacommon,serious,andpreventablecomplicationoftype1diabetes,withamortalityof35%. Diabetic ketoacidosis dka explained clearly remastered dka pathophysiology duration. The uk guideline differs in several ways from the us position statement. Dka at diagnosis is more common in children jun 30, 2014 diabetic ketoacidosis dka is a rare yet potentially fatal hyperglycemic crisis that can occur in patients with both type 1 and 2 diabetes mellitus. Due to its increasing incidence and economic impact related to the treatment and associated morbidity, effective management and prevention is key. Acute management of diabetic ketoacidosis in adults this protocol is for the acute management of diabetic ketoacidosis in patients 16 years and over. Diabetic ketoacidosis dka is a potentially lifethreatening complication of diabetes mellitus. Those with severe dka have a much higher mortality and risk of complications.
Dec 11, 2019 diabetic ketoacidosis is a serious complication of diabetes that occurs when your body produces high levels of blood acids called ketones. The uptake of a new dka protocol was studied in a retrospective audit of 46 dka episodes over a 4month period in 2008, with adherence rates above 70% in the initial hour table 6, although this declined after 1 h following commencement of treatment, resulting in incorrect fluids being administered and neglect in monitoring electrolytes. Medcram medical lectures explained clearly 37,403 views 11. Acute dehydration must be treated with iv fluid replacement. Diabetic ketoacidosis dka is an emergency for people with diabetes characterized by hyperglycemia, metabolic acidosis, and ketosis. Montefiore subcutaneous insulin dka protocol this is a subcutaneous subq insulin protocol that replaces insulin drip needs for mild to moderate dka. Omission of insulin is the most common precipitant of dka. Adult patients who received insulin aspart for treatment of dka at rush university medical center between january 2008 and december 2011. The protocol was adapted from the scottish national dka protocol 8 and modified to meet local practice need. Diabetic ketoacidosis american academy of pediatrics. Dka accounts for more than 150,000 hospital admissions per. Identify and treat the cause of the dka precipitation.
In 2009, there were 140,000 hospitalizations for diabetic ketoacidosis dka with an average length of stay of 3. If a patient has elevated bgl and ketones but is not acidotic they need to be closely monitored and agressively managed to prevent progression to dka. They are part of the spectrum of hyperglycemia, and each represents an extreme in the spectrum. During the dka therapy, complications may arise and appropriate. Near patient testing for 3betahydroxybutyrate is now readily available for the monitoring of the abnormal metabolite allowing for a shift away from using glucose levels to drive treatment decisions in the management of dka. These guidelines have been developed to reflect the development in. Page 1 of 7 hyperglycemic emergency management dkahhs1.
Feb 23, 2016 diabetic ketoacidosis dka explained clearly remastered dka pathophysiology duration. To minimize the risk of dka and still gain the multiple benefits, we developed the stop dka protocol, an easily accessible and practical tool, that provides a risk mit. In response to this imbalance, normal physiologic mechanisms are exaggerated, resulting in hyperglycemia, hyperosmolality, ketosis, and acidosis. Diabetic ketoacidosis dka and hyperosmolar hyperglycemic state hhs, also known as hyperosmotic hyperglycemic nonketotic state hhnk are two of the most serious acute complications of diabetes. Management of diabetic ketoacidosis in adults age 16. However, there are no studies to support this or any other specific bicarbonate treatment protocol in dogs and cats with dka. Dka is a complication of diabetes mellitus and mainly affects type 1 diabetics. Goals of therapy are to correct dehydration, correct acidosis and reverse ketosis, gradually restore hyperosmolality and blood glucose. Treatment of diabetic ketoacidosis with subcutaneous. These steps are summarized in table 1, outlining the stich protocol, a proposed early treatment regimen for patients to begin when they detect high ketone levels. The uk has separate guidelines onthe management of dka 7, while the usa has a position statement on dka and hhs that was updated in 2009 8. Although the diagnosis and treatment of diabetic ketoacidosis dka in adults and in.
Updates in the management of diabetic ketoacidosis the. Uptodate, electronic clinical resource tool for physicians and patients that provides information on adult primary care and internal medicine, allergy and immunology, cardiovascular medicine, emergency medicine, endocrinology and diabetes, family medicine, gastroenterology and hepatology, hematology, infectious diseases, nephrology and. This thesis surmises the treatment methodology as devised by the milwaukee protocol and attempts to evaluate the efficacy of this treatment over the period of 01. Prior emergency room visits and hospitalizations related to diabetes. Diabetic ketoacidosis dka is the most common hyperglycemic emergency in patients with type 1 and type 2 diabetes mellitus. Strategy for mitigating dka risk in patients with type 1.
Overall, the diagnosis and treatment of dka are very similar in the uk and usawith a few differences. Meticulous monitoring of the clinical and biochemical response to treatment is necessary so that timely adjustments in treatment can be made when indicated by the patients clinical or laboratory data e. To enhance collaborative patient care by referral of patients with a diagnosis of type 1 or type2 diabetes dm to be comanaged by the clinical pharmacist. Diabetic ketoacidosis dka is not a rare presentation to hospital, despite being an entirely preventable condition. Stanford hospital and clinics glycemic control of diabetes mellitus stanford coordinated care glycemic control of diabetes mellitus protocol stanford coordinated care page 1 purpose. The condition develops when your body cant produce enough insulin. There are no specific clinical signs that confirm or refute the diagnosis of dka. Emergency management of diabetic ketoacidosis in adults. Patients who selfdischarged against medical advice before resolution of acidosis and those who stayed in hospital for more than 96 h without ongoing issues with dka 5 in the protocol group and 4 in the control group were excluded. Endstage renal disease increases rates of adverse glucose. A persons breath may develop a specific fruity smell.
Acute complicationssevere hyperglycemia, dka, severe hypoglycemia requiring assistance of another, hypoglycemia unawareness. To transfer from iv to sc, continue iv insulin infusion for 1 to 2 hours after sc insulin is begun to. If protocol contraindicated or not ordered, notify physician. Family history of diabetes, chronic kidney disease, premature cardiovascular disease. Dka at diagnosis is more common in children pdf diabetic ketoacidosis dka is a rare yet potentially fatal hyperglycemic crisis that can occur in patients with both type 1 and 2 diabetes. Management of dka has changed in the last decade, and national guidelines introduced, to help standardise care, spread best practice, and reduce mortality and morbidity. Enhanced lipolysis increases serum free fatty acids that are then. History of infectionstype, treatment, resolution time. Signs and symptoms may include vomiting, abdominal pain, deep gasping breathing, increased urination, weakness, confusion and occasionally loss of consciousness. Insulin infusion should be continued until acidosis has resolved, as demonstrated by ph 7. Review of evidence for adult diabetic ketoacidosis.
Nurse practitioners are well positioned to promote patient education, selfmanagement, and individualized patient care. Hyperglycemic emergencies in adults diabetes guidelines. Procedures are adapted for covidrelated considerations of minimizing risk to staff while optimizing patient safety and health. Diabetic ketoacidosis dka nursing dka pathophysiology. Diabetic ketoacidosis dka is the most common hyperglycemic emergency in patients with diabetes. Diabetic ketoacidosis dka is a feature of type 1 diabetes and the risk is increased when sglt inhibitors are used in type 1 diabetes. Enhanced lipolysis increases serum free fatty acids. Diabetic ketoacidosis dka care guidelines emergency. Dka onset and recurrence can largely be prevented through patient education. Treatment of diabetic ketoacidosis dkahyperglycemic. Page 1 of 7 hyperglycemic emergency management dkahhs1 adult. Sep 01, 2018 emergency treatment should be sought if symptoms of dka occur, including abdominal pain, nausea, vomiting, fatigue, malaise, andor dyspnea. The treatment for euglycemic dka is similar to typical dka treatment 11 hydration. Management of diabetic ketoacidosis by michael agus, md.
Correct ketosis and acidosis with continuous insulin. Dka guideline for diagnosis hhs guideline for diagnosis. Insulin normally plays a key role in helping sugar glucose a major source of energy for your muscles and other tissues enter your. Diabetic ketoacidosis dka occurs when there is a relative or absolute decrease in circulating insulin levels in relation to an increase in counterregulatory hormone levels. A dka treatment protocol that uses subcutaneous insulin aspart, with weightbased doses administered every two hours, is safe and effective. This is the first and most important step in the initial management of dka patients. Diabetic ketoacidosis is characterized by a serum glucose level greater than 250 mg per dl, a ph less than 7. In the dkahhs management protocol, regular insulin administered by i. Dka in adolescents causes of morbidity and mortality. Because there is considerable individual variability in presentation of dka ranging from mild with only minimal dehydration to severe with profound dehydration, some patients may require specific treatment that, in the judgment of the treating phy. Hyperglycemic hyperosmolar syndrome used to be called honk hyperosmolar nonketotic dka and hhs absence of insulin increased glucagon increased diabetogenic hormones oxidation of free fatty acids ketones. Review of evidence for adult diabetic ketoacidosis management. This article outlines updates in the clinical management of.
Following the publication of the pekarn dka fluid trial new engl j med 2018. A concerning number of people also develop dka while already in hospital. Pdf diabetic ketoacidosis dka is a rare yet potentially fatal hyperglycemic crisis that can occur in patients with both type 1 and 2 diabetes. Dka treatment protocol barbara davis center for childhood. Goals of treatment replace volume deficit correct ketosis and acidosis with continuous insulin replace electrolyte deficits replace free water deficit prevent hypoglycemia determine inciting condition for the dka correct hyperglycemia secondary goal when dka resolved. Patient records were obtained from the rebro hospital archives and details on icu treatment of diabetic ketoacidosis were evaluated. A possible bicarbonate treatment protocol is to administer sodium bicarbonate at 12 to of 0. The diagnosis is comparatively straight forward where there is a clear history that the patient has diabetes but can cause serious diagnostic difficulty where the patient is unconscious or dka is the first presentation of diabetes a past history of diabetes mellitus will be absent in. Management of diabetic ketoacidosis by michael agus, md for. When glucose falls dka, and when patient is able to eat, initiate a multidose insulin regimen. Diabetic ketoacidosis symptoms and causes mayo clinic.
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