Predictors and treatment outcome of hyperglycemic emergencies at jimma university specialized hospital, southwest ethiopia treatment of diabetic ketoacidosis with subcutaneous insulin aspart diabetes care, aug 2004. In adults with dka or hhs, a protocol should be followed that incorporates the following principles of treatment. Potassium chloride 80 meq iv q6h prn for serum k 4 d. Protocol this trial protocol has been provided by the authors to give readers additional information about their work. Dka protocol the osmotic diuresis can cause a significant loss of fluid, leading to severe dehydration and circulatory collapse.
As treatment progresses, the glucose infusion rate will vary and is best managed with a standardized protocol. Initial management of the pediatric patient page 1. Correct ketosis and acidosis with continuous insulin. Dka treatment protocol diabetic ketoacidosis dka is a lifethreatening condition with characteristics of insulin deficiency and increased hormones of cortisol, glucagon, catecholamines, and growth hormones. Physicians should recognize the signs of diabetic ketoacidosis for. Diabetic ketoacidosis dka is a lifethreatening but preventable complication of diabetes characterized by uncontrolled hyperglycemia 250 mgdl, metabolic acidosis, and increased ketone concentration. These guidelines have been developed to reflect the development in. No other identifiable cause for dka all orders and protocol assumes previous treatment in the ed setting ed work up must include vbg, cmp and evaluation for other causes of dka mildmoderate dka as defined by ph 7. Treatment decisions should be timely and based on evidencebased guidelines that are tailored to patient preferences, prognoses, and comorbidities. Data sources medline via pubmed and embase 1 january 2000 to 23 june 2016. Guidelines for the management of adult patients with dka in. Diabetic ketoacidosis dka care guidelines critical care. This protocol is compiled using the ada guidelines of 2009.
Diabetic ketoacidosis dka critical care guideline two bag. Insulin infusion should be continued until acidosis has resolved, as demonstrated by ph 7. Incidence and prevalence of diabetic ketoacidosis dka. Signs and symptoms may include vomiting, abdominal pain, deep gasping breathing, increased urination, weakness, confusion and occasionally loss of consciousness. The barbara davis center provides stateof theart care to children and adults with type 1 diabetes and teaches our patients how to prevent or delay complications. Arkansas childrens hospital employs a 2bag iv fluid system initial 6 hours of treatment normal saline ns with 20 meq k acetatel and 20 meq kphosl and d10ns with 20 meq k acetatel and 20 meq kphosl. Phase type of fluid rate iv regular insulin endpointgoal 0. Diabetic ketoacidosis dka is a rare yet potentially fatal hyperglycemic crisis that can occur in patients with both type 1 and 2 diabetes mellitus. B providers should consider the burden of treatment and selfefficacy of patients when recommending treatments. The biochemical criteria for the diagnosis of diabetic ketoacidosis dka are. Diabetes is a common chronic condition and as of 2015, approximately 30 million persons in the united states had diabetes 23 million with diagnosed and 7 million with undiagnosed 1. No yes cbg is now greater than 4mmoll nb give once only. 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. Resolution of dka resolution of dka is defined as ph7.
Incidence and prevalence of diabetic ketoacidosis dka among. Determine the average hourly rate over the last 8 hours in unitshr and multiply by 24 hours b. Allow 30 minute overlap after 1st injection of rapidacting insulin before the insulin infusion is stopped. 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. C 3 cerebral edema is less common in adults than in children, and there are no studies in adults to report. Treatment of pediatric diabetic ketoacidosis in canada. Standards of medical care in diabetes2019 abridged for. 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.
Recommendations testing for prediabetes and type 2 diabetes in asymptomatic people should be considered in adults of any age who are overweight or obese bmi 25 kgm. Our research is devoted to finding prevention, cure, and most effective treatment of diabetes and associated disorders. If protocol contraindicated or not ordered, notify physician. The protocol was adapted in collaboration with the department of endocrinology for use in the internal medicine high care unit. To transfer from iv to sc, continue iv insulin infusion for 1 to 2 hours after sc insulin is begun to.
A persons breath may develop a specific fruity smell. Clinically significant cerebral edema can potentially develop within the first 412 hours after initiation of treatment for dka, but may also present before treatment, or as late as 2448 hours after treatment. Diabetic ketoacidosis dka, hyperglycaemic hyperosmolar state hhs and hypoglycaemia are serious complications of diabetes mellitus that require prompt recognition, diagnosis and treatment. British society of paediatric endocrinology and diabetes bsped guidelines for the management of dka in. Pdf diabetic ketoacidosis dka, resulting from severe insulin deficiency, accounts for most hospitalization and is the most common cause of death. Management of diabetic ketoacidosis in adults age 16. 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. A phase 3, randomized, doubleblind, placebo controlled. Determine the total daily insulin tdi requirement unitsday i. Objectives when the student has finished studying this module, heshe will be able. Dka guideline for diagnosis hhs guideline for diagnosis. Early recognition of dka, a good understanding of the pathological processes of dka, and aggressive treatment are the keys to successful treatment.
Guidelines 2 confirmation of dka diagnosis 3 treatment goals 3 insulin 4 iv fluids and hydration 4 dextrose,sodium, bicarbonate, potassium 6 monitoring parameters 7 4. Common dka precipitants include infection, mi or insulin omission. Guidelines for the management of patients with dka and hhs. Prebreakfast administer both glargine and aspart dose according to premeal aspart order set. Adult dka management these recommendations do not take into account individual patient situations, and do not substitute for clinical judgment. Diabetic ketoacidosis is characterized by a serum glucose level greater than 250 mg per dl, a ph less than 7. Diabetic ketoacidosis dka is a major acute metabolic complication of t1d that is typically marked by acidosis, ketosis and usually hyperglycaemia.
Ensure adequate potassium level before starting insulin therapy. The insulin deficiency and increased hormones lead to dehydration, electrolyte imbalances, hyperglycemia and ketosis. Following the publication of the pekarn dka fluid trial new engl j med 2018. Review of evidence for adult diabetic ketoacidosis management. Management of diabetic ketoacidosis in adults age 16 years. From 2000 to 2009, the ageadjusted rate of dka hospitalizations among persons with diabetes fluctuated but declined at an average annual rate of 1.
Trends in diabetic ketoacidosis hospitalizations and in. The outcomes of dka have been shown to improve with adherence to treatment guidelines. Page 1 of 7 hyperglycemic emergency management dkahhs1. E american diabetes association standards of medical care in diabetes. Full text management of adult diabetic ketoacidosis dmso. Barbara davis center for childhood diabetes, university of colorado. Omission of insulin is the most common precipitant of dka.
With good care, dka can be managed and the patient will survive. Regional practice guidelines for diabetic ketoacidosis dka. Pdf diabetic ketoacidosis dka is a rare yet potentially fatal hyperglycemic crisis that can occur in patients with both type 1 and 2 diabetes. 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. Diabetic ketoacidosis dka critical care guideline two. Diabetic ketoacidosis dka management algorithm adult. Sc insulin should be resumed after the patient is euglycaemic, ketone free and eatingdrinking normally. Goals of therapy are to correct dehydration, correct acidosis and reverse ketosis, gradually restore hyperosmolality and blood glucose. To determine the efficacy of phosphate replacement in the therapy for diabetic ketoacidosis dka, 44 patients were randomly assigned to three treatment groups. 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. Dka at diagnosis is more common in children pdf format the bcch dka nursing protocol 20191129 version.
Acute myocardial infarction, cva, trauma, sepsis protracted vomiting. They are part of the spectrum of hyperglycemia, and each represents an extreme in the spectrum. Change in blood glucose trend insulin infusion titration. Decrease rate of change of insulin infusion by 50% if blood glucose decreases by 100 mgdl per hour and notify physician. Montefiore is not responsible for anything resulting from the use of this protocol by anyone outside of montefiore. Individual rates of bag 1 and bag 2 are dependent on glucose level with goal of maintaining glucose of 150300. Barbara davis center home university of colorado school.
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