Dka charts что это

Dka charts что это

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

LTHT Guidelines for the Management of Diabetic Ketoacidosis in Adults (aged 18 years and over)

Summary Guideline

Background

Diabetic ketoacidosis (DKA) is a complex disordered metabolic state characterised by hyperglycaemia, acidosis, and ketonaemia. DKA usually occurs as a consequence of absolute or relative insulin deficiency that is accompanied by an increase in counter regulatory hormones (i.e., glucagon, cortisol, growth hormone, and epinephrine). This type of hormonal imbalance enhances hepatic gluconeogenesis and glycogenolysis resulting in severe hyperglycaemia.

Enhanced lipolysis increases serum free fatty acids that are then metabolised as an alternative energy source in the process of ketogenesis. This results in accumulation of large quantities of ketone bodies and subsequent metabolic acidosis. Ketones include acetone, 3-beta-hydroxybutyrate, and acetoacetate. The predominant ketone in DKA is 3-beta-hydroxybutyrate.

Epidemiology

DKA remains a significant clinical problem in spite of improvements in diabetes care. The incidence is thought to range between 4.6-8 episodes per thousand patients with diabetes.

Morbidity and mortality

Mortality rates have fallen significantly in the last 20 years through early diagnosis and implementation of effective prevention programs, and better understanding of the pathophysiology DKA with close monitoring and correction of electrolytes. The main causes of mortality are severe hypokalaemia, adult respiratory distress syndrome, and other comorbidities such as pneumonia, myocardial infarction and sepsis. In children and young adolescents cerebral oedema remains the most common cause of mortality.

Diagnosis

DKA consists of the biochemical triad of acidaemia, ketonaemia and hyperglycaemia. The following three mandatory features must be documented clearly.

Acidaemia

This is defined as a low blood bicarbonate level ( 3mmol/L suggest significant ketonaemia.
Blood ketone meters measure 3-beta-hydroxybutyrate, the most abundant ketone in DKA.

Ketonuria

2+ or greater ketones in the urine.
Urinalysis detects ketoacetate, which is produced in lower quantities than 3-beta-hydroxybutyrate in DKA. Urine ketones typically lag blood ketones.

Hyperglycaemia

Venous blood glucose >11mmol/L.
Ketoacidosis is possible with normal or only mildly elevated blood glucose values, especially in pregnancy.

Symptoms and signs

Symptoms

Excess urine production, excess thirst, blurred vision, vomiting, abdominal pain, infective symptoms

Signs

Fast heart rate, low blood pressure, fast respiratory rate, acetone smell on breath, signs of dehydration, tender abdomen, reduced conscious level.

Alternative hyperglycaemic Diagnoses

These DKA guidelines do not apply to the treatment of hyperosmolar hyperglycaemic state.

Investigations

Always, at presentation:

Often indicated (depending on clinical suspicion):

Sometimes indicated

Electrolyte measurements can be obtained from most blood gas analysers. These can be used to monitor potassium and bicarbonate levels. These should be corroborated with lab values at presentation and after six hours of treatment.

Other treatments

Thromboprophylaxis

DKA predisposes to venous thromboembolism. Unless contraindicated patients with DKA should be initiated on appropriate thromboprophylaxis. This should be based on LTHT Guidelines VTE Prophylaxis for General Medical patients.

Bicarbonate

Adequate fluid and insulin therapy will resolve the acidosis in DKA and the use of bicarbonate is not indicated. There is some evidence that the use of bicarbonate in DKA is detrimental.

Phosphate

Phosphate deficits in DKA may average one mmol per kilogram of body weight. There is no evidence of benefit of phosphate replacement in DKA. However in cases of severe or symptomatic hypophosphataemia, phosphate replacement should occur in line with LTHT Guideline Hypophosphataemia in Adults.

Monitoring

Venous blood gas measurements

Ketonaemia

When blood ketone monitoring is available, then these should be used to guide treatment.

If bedside blood ketone monitoring is not available the bicarbonate level can be used to assess response during the first 6 hours, along with falling blood glucose values and clearance of urine ketones.

CLINICAL

LABORATORY

Monitor capillary glucose and ketones hourly.

Regular clinical and biochemical reviews are needed during first 24 hours

1 hr

2 hr

4 hr

6 hr

12 hr

24 hr

Glucose

Potassium *

Creatinine

Bicarbonate *

Ketones

Hourly capillary or twice daily urine (if capillary ketones unavailable).

Arterial gas

If sats * Take venous blood in a gas syringe and analyse as Box 2.

Metabolic treatment targets

Resolution of DKA

Complications

Cerebral oedema

Cerebral oedema is relatively uncommon in adults during DKA. The symptoms to be aware of include headache, irritability, drowsiness or decreasing levels of consciousness Care must be taken when treating adolescents and young adults in particular. Cerebral oedema in DKA is much more common in children. Avoidance of overzealous fluid resuscitation in these patient groups is important.

Pulmonary oedema

Elderly patients and those with impaired cardiac function are at particular risk of pulmonary oedema, particularly in the first few hours of initiation of treatment. Care must be taken in these patient groups and monitoring of central venous pressure should be considered.

Expectation and outcome

Patients with diabetic ketoacidosis usually respond well and promptly to treatment. Failure to improve is important to recognise as it may well indicate an underlying illness or complication.

If the patients symptoms, overall clinical status, or serum bicarbonate do not improve or new adverse clinical features develop, an underlying illness or complication should be sought. In these circumstances consider seeking early advice from ITU/critical care reach.

Hypoglycaemia in DKA

How to manage hypoglycaemia in an adult patient with DKA?

Other considerations

In any patient admitted with DKA it is important to consider:

Special patient groups

The following groups of patients need specialist input as soon as possible and special attention with regards to fluid balance.

Elderly
Pregnant women (call diabetes team immediately)
Young people 18 to 25 years of age
Heart or kidney failure
Other serious comorbidities

The early involvement of diabetes specialist teams in these patient groups is crucial.

The diabetes specialist team

Diabetes specialist teams must always be involved in the care of those admitted to hospital DKA, ideally at presentation and definitely within 24 hours.. This has been shown to improve safety and shorten patient stay.

Diabetes specialists should also be involved in the assessment of the precipitating cause of DKA, management, discharge and follow-up. This will enable safer and more efficient patient care. This should also ensure rigorous implementation of DKA guidelines.

Provenance

Aims
To improve the diagnosis and management of adult patients with diabetic ketoacidosis (DKA) in Leeds Teaching Hospitals NHS Trust.

Objectives
To provide evidence-based recommendations for appropriate diagnosis, investigation and management of diabetic ketoacidosis in adults with Diabetes Mellitus (DM).

The guidelines which follow are designed to be used in conjunction with the DKA treatment chart (LTHT Adult Diabetic Ketoacidosis IV insulin treatment chart, Age 19 years and above)

Evidence base

Based on the Joint British Diabetes Societies Inpatient Care Group Management of DKA Guidelines in Adults, September 2013

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

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