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DKA management based on NICE guidelines UK
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Dka presentation
- 1. DR ABUBAKKAR RAHEEL INTERNAL MEDICINE TRAINEE YEAR-1 SHREWSBURY AND TELFORD HOSPITALS NHS TRUST ROYAL SHREWSBURY HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST DIABETIC KETOACIDOSIS (DKA)
- 2. DEFINITION • AN ACUTE, MAJOR, LIFE-THREATENING COMPLICATION OF DIABETES • CHARACTERIZED BY HYPERGLYCAEMIA, KETOACIDOSIS AND KETONURIA • ABSOLUTE OR RELATIVE INSULIN DEFICIENCY INHIBITS THE ABILITY OF GLUCOSE TO ENTER CELLS FOR UTILIZATION AS METABOLIC FUEL • LIVER RAPIDLY BREAKS DOWN FAT INTO KETONES TO EMPLOY AS A FUEL SOURCE. ROYAL SHREWSBURY HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
- 3. DEFINITION HYPERGLYCEMIA ACIDODISKETOSIS DK A ROYAL SHREWSBURY HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
- 4. PATHOPHYSIOLOGY ABSOLUTE OR RELATIVE INSULIN DEFICIENCY INCREASE IN COUNTER REGULATORY HORMONES – GLUCAGON, CORTISOL, GH, CATECHOLAMINES INCREASED HEPATIC GLUCONEOGENESIS AND GLYCOGENOLYSIS RESULTING IN SEVERE HYPERGLYCEMIA INCREASED FREE FATTY ACIDS – METABOLIZED AS ALTERNATE ENERGY SOURCE INCREASED KETONE BODIES ACCULMULATION ACETONE 3 BHB ACETOACETATE METABOLIC ACIDOSIS ROYAL SHREWSBURY HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
- 5. FLUID DEPLETION OSMOTIC DIURESIS DUE TO HYPERGLYCEMIA AND VOMITING DECREASED FLUID INTAKE DUE TO ALTERED CONSCIOUSNESS ROYAL SHREWSBURY HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
- 6. EPIDEMIOLOGY AND MORTALITY • 4.6 TO 8 EPISODES/1000 INCIDENCE OF DIABETES • 2017 NATIONAL DIABETES AUDIT: 1 IN 25 IN-PATIENTS WITH TYPE 1 DM DEVELOPED DKA • MORTALITY RATE FALLEN FROM 7.96% TO 0.76% IN LAST 20 YEARS • CAUSES OF MORTALITY • CHILDREN – CEREBRAL EDEMA • ADULTS – HYPOKALEMIA, ARDS, PNEUMONIA, ACUTE MI, INFECTIONS ROYAL SHREWSBURY HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
- 7. SIGNS AND SYMPTOMS • POLYURIA • HYPOTENSION • TACHYPNOEA • TACHYCARDIA • FEVER, IF INFECTION IS PRESENT • VOMITING AND DEHYDRATION • LABOURED BREATHING / HYPERVENTILATION • KETOTIC BREATH ROYAL SHREWSBURY HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
- 8. DIAGNOSIS – NICE KETONAEMIA >3.0 mmol/l or significant ketonuria (2+ on urine dip) Blood glucose >11 mmol/l or known diabetes mellitus Bicarb < 15.0 mmol/l and/or venous ph < 7.3 ROYAL SHREWSBURY HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
- 9. INITIAL MANAGEMENT • RAPID ABC • LARGE BORE IV CANNULA • INFORM SENIOR CLINICIAL / SPR / ON-CALL CONSULTANT • EXPLAIN TO PATIENT AND FAMILY • RECORD OBSERVATIONS (NEWS), CLINICAL EVIDENCE OF DEHYDRATION, BODY WEIGHT • THINK ABOUT NG TUBE IF CHILD/YOUNG PERSON VOMITING • THINK ABOUT SEPSIS IF FEVER/HYPOTHERMIA, LACTIC ACIDOSIS, HYPOTENSION, REFRACTORY ACIDOSIS • INFORM DIABETIC SPECIALIST NURSE ROYAL SHREWSBURY HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
- 10. INVESTIGATIONS CBG, VBG BLOOD KETONES U&ES BLOOD CULTURES ECG CHEST X RAY URINALYSIS AND CULTURE CONTINUOUS PULSE OXIMETRY ROYAL SHREWSBURY HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
- 11. FLUID AND INSULIN THERAPY • FLUID REQUIREMENT • 5% OF TOTAL BODY WRIGHT FLUID DEFICIT IN MILD TO MOD DKA (PH 7.1/ABOVE) • 10% OF TOTAL BODY WEIGHT FLUID DEFICIT IN SEVERE DKA (PH 7.1/BELOW) • MAINTENANCE FLUID • WEIGH <10KG - 2ML/KG/HR • WEIGHT 10-40KG – 1ML/KG/HR • ABOVE 40KG – FIXED VOL 4ML/KG/HR • INC RISK OF CEREBRAL EDEMA WITH LARGE FLUID VOL ROYAL SHREWSBURY HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
- 12. FLUID AND INSULIN THERAPY • 0.9% SALINE UNTIL BM <14MMOL/L • ADD 40MMOL/L KCL IN ALL FLIUD EXCEPT INITIAL BOLUS • URINARY CATHETER IF NOT ABLE TO MEASURE U/O • FIXED RATE INSULIN INFUSION 0.1UNIT/KG/HOUR VIA INSULIN PUMP – 50 UNITS ACTRAPID WITH 50ML 0.9% SALINE • DO NOT GIVE BOLUS OF IV INSULIN • CONTINUE SUB-CUT BASAL INSULIN/ LONG ACTING INSULIN • IF BM < 14MMOL/L – CHANGE FLUID TO 0.9% SALINE WITH 10% GLUCOSE (125ML/HR) AND 40MMOL/L KCL ROYAL SHREWSBURY HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
- 13. FLUID AND INSULIN THERAPY • IF GLUCOSE < 6MMOL/L • INCREASE GLUCOSE CONC OF IV FLUID • IF PERSISTENT KETOSIS • INC INSULIN DOSE BY 1UNIT/HR INCREMENT UNTIL TARGET ACHIEVED • IF KETOSIS RESOLVING • CONSIDER STOPPING IV FLUID THERAPY • START S/C INSULIN 30 MINS PRIOR TO STOPPING IV INSULIN ROYAL SHREWSBURY HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
- 14. FLIUD AND INSULIN THERAPY Fluid 0.9% NACL 1L – OVER 1 HR 0.9% NACL 1L + KCL – OVER 2 HRS 0.9% NACL1L + KCL – OVER 2 HRS 0.9% NACL1L + KCL – OVER 4 HRS 0.9% NACL 1L + KCL – OVER 4 HRS 0.9% NACL 1L + KCL OVER 6 HRSROYAL SHREWSBURY HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
- 15. 2 HDU • KETONES > 6MMOL/L • BICARB LEVEL < 5MMOL/L • VENOUS/ARTERIAL PH < 7.0 • HYPOKALEMIA < 3.5MMOL/L • GCS < 12 • O2 SATS < 92% ON AIR • BP SYS < 90MMHG • PULSE < 60BPM / >100BPM ROYAL SHREWSBURY HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
- 16. MONITORING • HOURLY MONITORING • CBG • NEWS • FLUID BALANCE • MOD GCS • 30 MIN MONITORING (SEVERE DKA) • MOD GCS • HR (DETECT BRADYCARDIA) • ECG FOR HYPOKALEMIA • ST DEPRESSION, U WAVES, TALL T WAVES ROYAL SHREWSBURY HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
- 17. MONITORING • 2 HRS FOLLOWED BY 4 HOURLY MONITORING • CBG • BLOOD GAS (PH AND BICARB) • PLASMA SODIUM, POTASSIUM, UREA • KETONES • FLUID BALANCE • CLINICAL STATUS • ECG TRACE ROYAL SHREWSBURY HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
- 18. RESOLUTION OF DKA CONTINUE IVII UNTIL THE FOLLOWING IS ACHIEVED • PH > 7.3 • BICARBONATE (HCO3) > 15.0 MMOL/L AND • BLOOD KETONE < 0.6 MMOL/L • PATIENT EATING AND DRINKING ROYAL SHREWSBURY HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
- 19. COMPLICATIONS • CEREBRAL EDEMA • MANNITOL 20% 0.5-1G/KG OVER 10-15 MINS OR • HYPERTONIC 3% SALINE 2.5-5ML/KG OVER 10-15 MINS • SPECIALIST ADVICE FOR BEST CARE SETTING • HYPOKALEMIA < 3.0 • CONSIDER SUSPENDING INSULIN INFUSION • CVP FOR IV KCL >40MMOL/L • VTE ROYAL SHREWSBURY HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
- 20. DISCUSSION • ABG VS VBG? • KETONEMIA - HALLMARK OF DKA • COLLOID VS CRYSTALLOID? • SALINE VS HARTMANN’S? • CAUTIOUS FLIUD REPLACEMENT • CONTINUING BACKGROUND INSULIN? ROYAL SHREWSBURY HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST
- 21. ROYAL SHREWSBURY HOSPITAL SHREWSBURY AND TELFORD HOSPITALS NHS TRUST THANK YOU14 NOV 2019