13:30-14:30 Diabetic Ketoacidosis

14:30-15:15 Oxygen Therapy

15:15-15:30 BREAK

15:30-16:30 Sepsis

25-year-old male with type 1 diabetes lantus 26 units ON and novorapid 12 units TDS recurrent attendances with DKA admitted with 24h history of vomiting and

abdominal pain on admission;

› CBG 18mmol/l› blood ketones 6.7mmol/l› pH 7.11› bicarbonate 9mmol/l

IS THIS DKA?

1. Diabetes› CBG >11.1 mmol/l OR known diabetes

2. Ketosis› capillary blood ketones ≥3.0mmol/l OR urine ketones ≥3+

3. Acidosis› pH <7.30 OR bicarbonate ≤15mmol/l

have to have all 3 (high BMs plus ketones without acidosis ≠ DKA)

CBG may be relatively normal e.g. pregnancy (euglycaemic DKA)

many unwell patients with T2DM have acidosis and ketosis (e.g. from vomiting, sepsis and renal failure) ≠ DKA

1. Fluid Resuscitation

2. Clearance of ketones and resolution of acidosis - insulin

3. Prevention and treatment of low K+ (hypokalaemia)

4. Identification and treatment of precipitating cause

5. Monitoring (ketones, glucose, K+, other complications)

6. Patient education and referral to diabetes specialist team

NOT getting the BM down as quickly as possible!

• fluid deficit in DKA up to 100ml/kg =7l for 70kg person (more if sepsis)• deficits in sodium (10mmol/kg), chloride and potassium (3-5mmol/kg)• aim to correct over 24h using 0.9% saline

› 1l stat› 2l over next 4h (500ml/h)› 2l over next 8h (250ml/h)› 2l over next 16h (125ml/h)

start 10% glucose infusion at 125ml/h when CBG <14mmol/l› 0.9% saline should usually continue alongside the glucose infusion

DO NOT stop 0.9% saline when starting 10% glucose within first 24h as dextrose will not replace intravascular volume

• 50 units actrapid in 50ml 0.9% saline giving a 1unit/ml solution• FIXED RATE IV INSULIN INFUSION (FRIVII)

› start at 0.1 units/kg/h = 7 units/h = 7ml/h in a 70kg person

› NOT variable rate IV insulin infusion (VRIVII, ‘sliding scale’)

› rate of insulin does NOT go up/down depending on CBG (BM)• aim for fall in ketones of ≥0.5mmol/h

› fall in blood glucose of 3mmol/h NOT as important• if this is not being achieved i.e. ketones not falling by 0.5mmol/h

› check insulin infusion (rate, lines, venflon, volume TBI)

› increase insulin infusion rate by 1unit (1ml)/h and monitor

• if patient takes long-acting insulin e.g. Lantus® or Levemir ensure this is written on drug chart and is given ALONGSIDE the IV insulin infusion

• if patient is normally on a SC insulin infusion pump ensure this is set to basal rate only BEFORE starting the DKA protocol

• FRIVII can be stopped when BOTH ketosis and acidosis have resolved i.e. pH >7.30 AND ketones <0.3mmol/l

› if patient eating and drinking switch to normal SC insulin (continue IV insulin for 30-60 minutes overlap AFTER first SC insulin dose)

› if patient not E&D, vomiting or septic switch to VRIVII protocol (‘sliding scale’)

• although K+ is frequently normal on admission, total body stores of K+ are usually low and serum potassium level will fall rapidly after starting IV insulin

• first litre of IV fluid usually given stat without adding any KCl

• potassium should be added to subsequent bags depending on repeated measurements of serum K+

• check VBG +/- U&E at least 4h during first 24h

Serum Potassium (mmol/l) Amount of KCl to add per litre of fluid (mmol/l)

≥5.5 0

4.5-5.5 20

<4.5 40

• new diagnosis of T1DM

• infection/sepsis

• MI

• missed insulin doses in known T1DM› often intentional as a form of repeated self-harm behaviour

bloods, CXR, urinalysis, ECG, blood cultures, stool cultures etc.

• hourly obs including GCS/urine output (consider catheter) if severe DKA

• hourly CBG AND blood ketones (document religiously!)

• fluid balance chart

• keep checking….. – insulin running at correct rate and no problems with pump etc.

– fluids are being given in time with prescribed schedule

• gently ‘remind’ doctors…..

– to repeat U&E plus VBG (at least every 4h)

– to increase insulin rate if ketones not falling adequately

– to add potassium to fluids

• hypokalaemia – risk of life threatening arrhythmias

• cerebral oedema (adolescents and children)

• pneumonia (including aspiration)

• MI

• venous thromboembolism (ensure Clexane® is prescribed)

• hypoglycaemia

• hypomagnesaemia and hypophosphataemia

• hypoxaemia and ARDS

MORTALITY still 2-5%

• diagnosed with DKA• 3L of 0.9% saline written up over first 4h• started on FRIVII at 6units(ml)/h (60kg)• 26 units of lantus prescribed on drug chart• after 2h blood ketones are 6.3mmol/L (6.7)• insulin being delivered at correct rate• insulin rate increased to 7units(ml)/h• 2h later ketones 4.2mmol/L and CBG 12mmol/L

• second cannula sited and 10% glucose started at 125ml/h in addition to 0.9% saline continued

• nurse repeats VBG and informs doctor that K+ is 3.8mmol/l• 40mmol KCl added to next 2 litres of 0.9% NaCl• CXR shows R basal pneumonia; IV abx given• after 12h VBG is repeated and shows pH 7.33 and

bicarbonate 18mmol/l; blood ketones now 0.2mmol/l• patient still not eating and drinking• VRIVII (‘sliding scale’) commenced and patient transferred to

Ward 9 for ongoing care

• doctor, doctor the ketones/BMs are not falling…

– insulin infusion running at 0.1ml/h rather than 7ml/h (0.1u/kg/h)

– line from insulin pump clamped off

– venflon removed and trickling insulin into patient’s mattress

– pump constantly alarming so only 14 units given over 6h (42 units)• patient collapsed in toilet due to severe hypoglycaemia; SC insulin pump still

running despite being started on FRIVII• no IV insulin running for 4h as nurse wanted to ‘wait until decision made on

Consultant ward round’; patient rebounded back into DKA • long-acting insulin not written up on drug chart• 0.9% saline stopped when 10% glucose commenced before patient

adequately rehydrated• VRIVII (‘sliding scale’) being used instead of FRIVII• ketones not regularly being checked with BMs

• 20 consecutive cases of DKA admitted to AMU• not 1 case managed completely in accordance with 2010 JBDS DKA guidelines • inadequate initial fluid resuscitation in 45%• 10% glucose not commenced when BM <14mmol/l in 50%• FRIVII not delivered or delivered incorrectly in 30%• CBG and ketones not checked/documented hourly in 35%• failure to adjust FRIVII appropriately in 55%• long acting SC insulin not prescribed in 50%• insulin written up in 5 different places (sometimes multiple prescriptions)• inadequate potassium replacement in 70%• no septic screen in 65%• inadequate repeat U&E/VBG in 70%

• poor awareness/understanding of new DKA guidelines (medical and nursing)

• confusion regarding the use of FRIVII vs VRIVII and the need for continued rehydration after commencing 10% glucose

• multiple versions of DKA guideline in circulation

• documentation of IV insulin, IV fluids, BMs/ketones in multiple different places on drug charts, IV fluid charts etc.

• tends to affect older type 2 diabetics• glucose often much higher than in DKA (usually >30mmol/l)• more profound dehydration (sodium very high and fluid deficit >10l)• acidosis not required for diagnosis (often acidotic due to sepsis or AKI)• ketosis may be present due to starvation/acute illness (rarely >3.0mmol/l)• fluid deficit should be corrected more slowly e.g. over 72h• FRIVII is not required (use VRIVII, 50% of usual dose if insulin naïve)• 10% dextrose is rarely required• invariably associated with severe precipitating illness e.g. MI, sepsis• prognosis much worse (mortality up to 50%)

we need to improve – Nurses and ACPs need to lead management

fluid resuscitation is the most important part of initial treatment

fixed rate IV insulin infusion (FRIVII) NOT sliding scale (VRIVII)

check CBG (BM) and blood ketones HOURLY

if ketones not falling by 0.5mmol/h check pump and lines BEFORE increasing insulin rate by 1unit(ml)/h

give long acting SC insulin AS WELL AS IV insulin

remember to check patients for SC insulin infusion pumps

start 10% glucose when CBG <14mmol/l but CONTINUE 0.9% saline AS WELL

frequent monitoring/obs and repeat U&E/VBG

ADEQUATE potassium replacement

identify and treat cause, monitor for complications