Chart No. ....................

WARD: ..................................

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Bwrdd Iechyd Prifysgol Betsi Cadwaladr University Health Board

ADULT DIABETIC KETOACIDOSIS PRESCRIPTION CHART

(PLEASE REFER TO GUIDELINES ON PAGES 2 & 3 AND MONITORING CHART ON PAGE 4)
Date: ...........................................................................

24

addressograph label
1) INTRAVENOUS FLUIDS

21

Ward: .......................................................................... Consultant: .................................................................. Patients weight (kg): ...................................................

19

20

TREATMENT AIM: Blood ketones to fall by at least 0.5mmol/L/hr Blood glucose to fall by at least 3mmol/L/hr Venous bicarbonate to rise by 3mmol/L/hr RESOLUTION OF DKA: Blood ketones less than 0.3mmol/L and pH > 7.3

should be commenced via a large IV cannula (green or grey). If there is a problem with intravenous access critical care support should be requested immediately. Be aware of any fluids that may have already been given in the ambulance on the way to the hospital. Rate mL / hour (circle as appropriate) Bag 1 0.9% sodium chloride 1 Litre over 1st hour 1000 / other * ................
Prescriber & bleep No. Administered by 2nd Nurse check Time & date commenced

MONITORING CHART FOR ADULT PATIENTS IN DIABETIC KETOACIDOSIS

HOSPITAL NUMBER: ......................................

16

17

18

* A slower rate and reduced volume of infusion should be considered when patients are under 25 years of age or over 70 years of age, pregnant, patients with heart or known chronic kidney failure (eGFR <30mL/min and dialysis patients refer to nephrologist on call) If systolic BP <90mmHg give 500ml over 10-15 minutres (see Box 1 on page 2.) Check potassium and correct as appropriate.

14

15

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STANDARD INFUSION RATE: AMEND ACCORDING TO PATIENT STATUS

Rate mL / hour

Potassium

Prescriber & bleep No.

Administered by

2nd Nurse check

Time & date commenced

(circle as appropriate) (circle as appropriate)

12

Bag Bag Bag Bag Bag Bag

2 3 4 5 6 7

0.9% sodium chloride 1 Litre / 2 hours 0.9% sodium chloride 1 Litre / 2 hours 0.9% sodium chloride 1 Litre / 4 hours 0.9% sodium chloride 1 Litre / 4 hours 0.9% sodium chloride 1 Litre / 6 hours 0.9% sodium chloride 1 Litre / 6 hours

500 / other ................ Nil / 40mmol / other .......... 500 / other ................ Nil / 40mmol / other .......... 250 / other ................ Nil / 40mmol / other .......... 250 / other ................ Nil / 40mmol / other .......... 166 / other ................ Nil / 40mmol / other .......... 166 / other ................ Nil / 40mmol / other ..........

10

11

PATIENTS NAME: ........................................................................

By 24 hours the ketonaemia and acidosis should have resolved. Continue IV fluids if patient is not yet eating & drinking as per clinical judgement. Bag 8 0.9% sodium chloride 1 Litre / 166 / other ................ Nil / 40mmol / other .......... 6 hours Bag 9 0.9% sodium chloride 1 Litre / 166 / other ................ Nil / 40mmol / other .......... 6 hours Bag 10 0.9% sodium chloride 1 Litre / 166 / other ................ Nil / 40mmol / other .......... 6 hours Bag 11 0.9% sodium chloride 1 Litre / 166 / other ................ Nil / 40mmol / 6 hours other .......... MONITOR PATIENT FOR FLUID OVERLOAD AND CEREBRAL OEDEMA
Any sudden deterioration in the patients level of consciousness should be considered as likely cerebral oedema until definitively proven otherwise

If blood glucose less than 14 mmol/L then prescribe 10% glucose 1 litre at 125mL/hour to run alongside sodium chloride
Rate mL / hour (circle as appropriate)
Prescriber & bleep No. Administered by 2nd Nurse check

Time & Date Commenced

10% glucose 1 Litre 10% glucose 1 Litre 10% glucose 1 Litre 35 30 25 15 10 40 20 5 10% glucose 1 Litre

125 / other ................ 125 / other ................ 125 / other ................ 125 / other ................

Bwrdd Iechyd Prifysgol Betsi Cadwaladr University Health Board

2) POTASSIUM PRESCRIPTION ADVICE

Capillary Glucose (mmol/L) (measure hourly and plot result on graph) Insulin (0.1 unit/kg/hr) (units/hr) 0.9% sodium chloride (mL/hour) 10% glucose (mL/hour) Blood ketone - hourly until <0.3mmol/L (mmol/L) Venous pH Over 5.5 3.5 to 5.5 Below 3.5

Start 10% glucose when glucose <14mmol/L

(If rate of potassium exceeds 10mmol/hour, cardiac monitoring is essential). Potassium level in first 24 hours (mmol/L) Potassium replacement in mmol/L of infusion solution Nil 40mmol/L Senior review, since additional potassium needs to be given or Humulin S)

3) INSULIN (Human soluble insulin e.g. Human Actrapid

Venous Potassium (mmol/L) Venous Bicarbonate (mmol/L)

Start IV insulin infusion via a pump, containing 50 units Actrapid insulin in 50mL 0.9% sodium chloride at a continuous fixed rate of 0.1 units/kg/hr. If unable to weigh patient then estimate weight. Monitor ketones and capillary blood glucose hourly and adjust rate as per guidance over page. If patient normally takes long acting insulin such as Glargine (Lantus) or Detemir (Levemir) subcutaneously, continue this at the usual dose and time, prescribe on in-patient drug chart.

Hours from start

INSULIN
Actrapid 50 units in 50mL sodium chloride 0.9% Actrapid 50 units in 50mL sodium chloride 0.9% Actrapid 50 units in 50mL sodium chloride 0.9% Actrapid 50 units in 50mL sodium chloride 0.9%

Initial rate mL / hour

Date:

Clock time

Prescriber and bleep No.

Administered by

2nd Nurse check

Time & Date Commenced

Written by Diabetes Team March, 2011

CD 792

W.W.&S

Written by Diabetes Team March, 2011

Bwrdd Iechyd Prifysgol Betsi Cadwaladr University Health Board

DIAGNOSIS:

GUIDELINES FOR THE MANAGEMENT OF DIABETIC KETOACIDOSIS (DKA) IN ADULTS

(Note - these are a guide only and may need to be varied in individual cases)

Bwrdd Iechyd Prifysgol Betsi Cadwaladr University Health Board

All 3 of the following must be present:G Capillary blood glucose over 11mmol/L or known diabetes mellitus G Blood ketones above 3mmol/L or urine ketones ++ or more G Venous pH less than 7.3 &/or bicarbonate below 15mmol/L

The presence of one or more of the following may indicate severe DKA and admission to a Level 2/HDU environment, insertion of a central line and immediate senior review should be considered
G G G G G

Blood ketones above 6mmol/L Venous bicarbonate level below 5mmol/L Venous pH below 7.1 Hypokalaemia on admission (below 3.5 mmol/L) GCS less than 12

G Oxygen saturation below 92% on air (assuming normal baseline respiratory function) G Systolic BP below 90 mmHg G Pulse over 100 or below 60 bpm G Anion gap above 16 (Anion Gap = (Na+ + K+) - (CI- + HC03-))

BOX 1: Immediate management upon diagnosis: (0 to 60 minutes)

(T=0 at time intravenous fluids are commenced) Action 1: Commence 0.9% sodium chloride infusion
(use large bore cannula) via infusion pump
G

BOX 2: Subsequent management (60 minutes to 6 hours)

Aims of treatment: G Rate of fall of ketones of at least 0.5mmol/L/hr OR a bicarbonate rise of 3mmol/L/hr and blood glucose fall of 3mmol/L/hr G Maintain serum potassium in normal range G Avoid hypoglycaemia, aim for a capillary blood glucose of 8-12mmol/L
Aims:
G G G G

BOX 3: 6 to 12 hours

BOX 4: 12 to 24 hours
By 24 hours the ketonaemia and acidosis should have resolved. If not improving seek senior review and review fluids and insulin infusion (BOX 2) At 12 hours check: venous pH, potassium, bicarbonate, capillary ketones and glucose Aim:
G Ensure that clinical and biochemical parameters

Systolic BP on admission 90 mmHg and over follow fluid replacement schedule on page 1: When systolic BP on admission is below 90 mmHg follow box below:

Ensure clinical and biochemical parameters improving Continue IV fluid replacement Avoid hypoglycaemia Assess for complications of treatment e.g. fluid overload, cerebral oedema G Treat precipitating factors as necessary

Hypotension is likely to be due to low circulating volume, but consider Action 1: Re-assess patient (vital signs) - continue to monitor: other causes such as heart failure, sepsis, etc. G Hourly capillary blood glucose and ketones (lab glucose if meter G Give 500mL of 0.9% sodium chloride solution over 10 to reading HI) 15 minutes. If SBP remains below 90 mmHg this may be G Venous blood gas for pH, bicarbonate and potassium at repeated whilst awaiting senior input. In practice most 60 minutes, 2 hours, and 2 hourly thereafter G For potassium replacement follow table on page 1 patients require between 500 to 1000mL given rapidly. G If potassium outside normal range, re-assess potassium G Consider involving the ITU/critical care team. replacement and check hourly. If abnormal after further hour G Once SBP above 90mmHg give 1000mL 0.9% sodium seek senior medical advice chloride over next 60 minutes. Addition of potassium likely G Complete DKA monitoring form on Page 4 for all monitoring to be required in second litre of fluid. parameters. Action 2: Insulin - commence fixed rate intravenous insulin Action 2: Continue fluid replacements via infusion pump Follow fluid replacement schedule on Page 1 - when blood glucose is infusion (IVII)
G 0.1 unit/kg/hr based on estimate of weight G Prefilled syringes: 50units human soluble insulin

Re-assess patient, monitor vital signs If patient not improving by criteria in BOX 2 seek senior advice Action 1: Continue IV fluid replacement Follow fluid replacement schedule on Page 1 (Check for fluid overload and cerebral oedema) Action 2: Review biochemistry/Insulin infusion At 6 hours check: venous pH, potassium, bicarbonate, capillary ketones and glucose

are continuing to improve or are normal

G Continue IV fluids if patient not eating or drinking G If ketoacidosis resolved (see definition BOX 3) and patient

is NOT eating or drinking move to sliding scale insulin as per local guidelines cerebral oedema

G Re-assess for complications of treatment e.g. fluid overload and

G If ketoacidosis resolved and patient is eating and drinking

(Actrapid) in 50mL sodium chloride 0.9%

G If patient usually takes long-acting insulin analogue e.g.

less than 14mmol/L ADD 10% glucose to run alongside sodium chloride 0.9% DO NOT STOP INSULIN INFUSION

Definition of resolution = ketones less than 0.3mmol/L and pH above 7.3 (do not use bicarbonate at this stage)
If DKA resolved: go to insulin sliding scale as per local guidelines until patient eating and drinking If DKA not resolved: review insulin infusion (see BOX 2, Action 3)

normally transfer to subcutaneous insulin and stop IV glucose & sodium chloride infusions

Action 3: Assess response to treatment with Insulin infusion, rate may need review if: G Capillary ketones not falling by at least 0.5mmol/L/hr Action 3: Assess patient clinically (see above guidelines for patients with G Venous bicarbonate not rising by at least 3mmol/L/hr DKA requiring HDU/ITU input) G Plasma glucose not falling by at least 3mmol/L/hr G Respiratory rate, temp, BP, pulse, oxygen sats G If ketones and glucose not falling as expected check for insulin G Glasgow coma scale infusion pump malfunction G Full clinical examination G If pump working but response inadequate - increase insulin infusion by 1 unit/hr increments until targets achieved Action 4: Further investigations Capillary and lab glucose, venous blood gases, U&E, blood ketones, FBC, METABOLIC TARGET: CXR, blood cultures, urinalysis and culture, ECG & MI screen (in high risk Continue fixed rate IVII until ketones less than 0.3mmol/L, venous group). (Lantus or Levemir) then continue at usual dose and time Action 5: Establish monitoring regimen - see 24 hour DKA monitoring achieved commence standard hospital sliding scale rate of insulin. form (page 4) Additional measures: G Capillary glucose and ketones, venous bicarbonate, potassium, G Accurate fluid balance chart U&E to be repeated at 60 minutes. G Consider urinary catheter if incontinent or anuric by 60 minutes G Continuous cardiac monitoring and/or pulse oximetry (if required) G Nasogastric tube with airway protection if patient obtunded or persistently vomiting Action 6: G Measure ABG and repeat CXR if oxygen saturation <92% G Consider precipitating causes and treat appropriately G Ensure referral to Diabetes Team G Consider thromboprophylaxis

DO NOT DISCONTINUE IV INSULIN INFUSION UNTIL 30 MINUTES AFTER SHORT ACTING SUBCUTANEOUS INSULIN HAS BEEN GIVEN
G

For Diabetes Team review before discharge

BICARBONATE: Sodium bicarbonate is RARELY necessary and may cause harm - refer to ITU if pH <7.1.

pH over 7.3 and/or venous bicarbonate over 18mmol/L. Once

Written by Diabetes Team March, 2011

Written by Diabetes Team March, 2011