DO NOT USE FOR CLINICAL PRACTICE
Please use current guidelines available on the UHNM intranet for patient treatment
Please use current guidelines available on the UHNM intranet for patient treatment
RECOGNITION AND ASSESSMENT
- Use this guideline only in patients who have metabolic acidosis
- For symptoms and signs, investigations and to check you are using the correct guideline, use Hyperglycaemia: triage guideline
Definition
- Severe uncontrolled diabetes with:
- capillary ketones (≥3 mmol/L)
- metabolic acidosis (pH <7.3, HCO3 <15 mmol/L)
- usually with hyperglycaemia (blood glucose >12 mmol/L)
- Beware of normoglycaemic Diabetic Ketoacidosis (DKA)
High-risk patients
- Severe DKA with
- capillary ketones >6 mmol/L
- venous HCO3 <5 mmol/L
- venous pH <7.1
- hypokalaemia <3.5 mmol/L on admission
- GCS <12
- SpO2 <92% on air
- systolic BP <90 mmHg
- pulse rate >100 or <60 bpm
- Anion gap >16 [anion gap = (Na+ + K+) - (Cl- + HCO3-)]
- Young patients (aged 18-25 yr)/elderly
- Pregnant patient
- manage in critical care area and involve obstetric team
- Heart/renal failure
- Other/serious co-morbidities
Search for precipitating causes
- Sepsis (signs of shock)
- Recent myocardial infarction
- Pancreatitis
- Other causes
Investigations for causes
- Serum amylase
- MSU
- If symptoms suggest sepsis, blood culture - see Blood culture guideline
- ECG
- Chest X-ray
GENERAL MANAGEMENT
- Treat cause
- Start on prophylactic LMWH unless contraindication
- If patient febrile and septic and no obvious cause can be found, see Sepsis guideline
- If patient hypotensive or comatose, or fails to pass urine within 3 hr of starting IV fluids, introduce urethral catheter to monitor urine volume
- see Urethral catheterisation guideline
- If hypotension persists beyond 6 hr, look again for evidence of sepsis, myocardial infarction or pancreatitis
- discuss further management with medical SpR
- consider transfer to critical care
- If GCS <8, request review by critical care team for endotracheal intubation and insertion of a nasogastric tube in order to aspirate stomach
- If not on critical care, admit patient to endocrinology ward
DELIVERY OF FLUID AND INSULIN
- Deliver insulin and IV fluid simultaneously
- only via a set incorporating anti-reflux valves through single cannula
- see Administration of IV insulin infusions and fluid infusions guideline
- Do not use ordinary 3-way taps
- Use IVAC pump to control IV fluid infusion rate and to alert when fluid bag needs replacing
- Never give single doses of insulin (e.g. Actrapid®)
INITIAL FLUID
- Start fluid replacement before commencing insulin and then run concurrently
First hour
- If initial systolic BP <90 mmHg, give 500 mL sodium chloride 0.9% over 15 min
- if BP remains low, give repeat fluid challenge and seek senior/critical care support early
- If initial systolic BP ≥90 mmHg, commence sodium chloride 0.9% IV 1 L over 1 hr
At 60 min (then every 2 hr)
- Potassium (K+) review
- take venous blood gas (VBG) for K+ (and pH)
Choice of fluid
- NEVER add potassium chloride to infusion bags
- Select pre-mixed bags of sodium chloride 0.9% and potassium chloride
- serum K+ ≥5.5 mmol/L, give 1 L bag of sodium chloride 0.9%
- serum K+3.5-5.4 mmol/L, give 1 L premixed bag of sodium chloride 0.9% with 40 mmol potassium chloride
- serum K+ <3.5 mmol/L, give two 500 mL premixed bags of sodium chloride 0.9% with 40 mmol potassium chloride - seek senior/critical care help
- Do not prescribe any potassium supplement in first litre of fluid
- addition of potassium is likely to be required in second litre of fluid
- If patient is anuric, do not give potassium
- While potassium is being infused, ideally attach patient to cardiac monitor
- administration rate above 20 mmol/L/hr requires cardiac monitoring
- K+ concentrations >40 mmol/L are painful and may cause severe phlebitis
- give via central line
- if central line cannot be inserted, administer via largest suitable peripheral vein using infusion pump
Rate after first 60 min
- Give chosen pre-mixed bags of sodium chloride 0.9% and potassium chloride
- 1 L over 2 hr; if giving 500 mL bags, first over 1 hr, next over following 1 hr; then
- 1 L over 2 hr; if giving 500 mL bags, first over 1 hr, next over following 1 hr; then
- 1 L every 4 hr; if giving 500 mL bags, first over 2 hr, next over following 2 hr; then
- continue as indicated by volume status (consider slower infusion rate in young adults as increased risk of cerebral oedema)
INITIAL INSULIN
Background subcutaneous Insulin
- Continue long-acting insulin [e.g. glargine (Lantus, Toujeo, Semglee, Abasaglar), detemir (Levemir) or degudec (Tresiba)®] if patient is already on it
- advise nurse to administer alongside IV insulin
- If patient on subcutaneous insulin pump (CSII), discontinue pump
- contact diabetes team or consultant in charge of patient
IV insulin delivery and infusion
- Use BD micro-fine insulin hypodermic syringes to accurately dose and draw insulin
- do not use ordinary syringe
- 50 units soluble insulin (Actrapid® or Humulin® S) diluted to 50 mL with sodium chloride 0.9% in 50 mL syringe
- Luer-lok through a spiral or long line delivered by syringe driver pump (so each mL equates to 1 unit of insulin)
Rate
- Commence insulin infusion using standard concentration of 50 units soluble insulin/50 mL sodium chloride 0.9%
- Infuse at rate of 0.1 units/kg/hr (e.g. 60 kg- 6 units/hr). Maximum 15 units/hr
- use patient's actual weight (if not available, ask patient/estimate weight)
MONITOR
- Maintain a strict fluid intake/output chart
- Remember: always assess patient clinically for fluid status and response to treatment
- While potassium is being infused, attach cardiac monitor to patient
- Capillary glucose hourly for 6 hr, then 2-hrly if patient stable
- Capillary ketones hourly until falls to <0.6 mmol/L
- Lab glucose, U&E, VBG 2 hr and 4 hr; then 2-4 hrly glucose and U&E till stable
- Monitor patient for complications of over-rapid treatment:
- hypoglycaemia
- cerebral oedema (decreased conscious level +/- focal neurological deficit) in absence of hypoglycaemia
- Adult respiratory distress syndrome (ARDS); hypoxia resistant to high FiO2 - seek critical care opinion
- Do not use flash glucose monitoring (Freestyle Libre, Dexcom G6) to guide treatment
- use in DKA/HHS is not evaluated
6-12 HR FOLLOWING ADMISSION
- Remember: always assess patient clinically for fluid status and response to treatment
- Assess for resolution (pH >7.3, capillary ketones <0.6 mmol/L)
- do not rely on HCO3- at this stage due to hyperchloraemia from large volume sodium chloride 0.9% infusion
- Treat any complications (e.g. fluid overload)
- Identify and treat any precipitating cause
Fluid replacement
- If blood glucose falls below 14 mmol/L, commence glucose 10% at 125 mL/hr alongside sodium chloride 0.9%
- caution in elderly, CCF, renal failure
Insulin
- If capillary ketones not falling by 0.5 mmol/L/hr, increase infusion rate by 1 unit/hr until this is achieved
- always check insulin infusion pump is working
- if ketone measurement not possible, HCO3- to increase by 3 mmol/L/hr, blood glucose to reduce by 3 mmol/L/hr
- When blood glucose is <14 mmol/L, consider reducing insulin infusion to 0.05 units/kg/hr to avoid hypoglycaemia
- e.g. for 60kg body weight reduce insulin rate to 3 units/hr
- Continue insulin infusion until capillary ketones <0.6 mmol/L, venous pH>7.3 and/or HCO3- >18 mmol/L, then convert to SC insulin regimen
- Do not discontinue IV insulin until 30 mins after starting SC insulin regimen
CONVERSION FROM IV INSULIN
- Once patient biochemically stabilised (pH >7.3, capillary ketones <0.6 mmol /L) and able to eat and drink, convert to SC insulin regimen
Patient can't eat/drink
- When ketones normal and acidosis resolved, convert to variable rate insulin infusion as in Hyperglycaemia: can't eat/drink guideline
- Assess fluid requirement clinically and involve diabetes team
SC insulin
- Transition from IV to SC insulin should take place when the next meal-related SC insulin dose is due (e.g. with breakfast or lunch)
- If already on insulin, continue fixed-rate infusion for 30-60 min after SC insulin administration in conjunction with a meal
Previously using SC insulin dose
- Restart usual insulin
- increasing previous dose by 10-20% for first 2-3 days
Insulin naïve patients
- Seek assistance from diabetes team for SC insulin initiation
- Continue insulin infusion until seen by diabetes team
Adjusting SC insulin regimen
- Once patient using SC insulin regimen, adjust doses to achieve target range of 6-11 mmol/L
- if using soluble insulin before breakfast, lunch and dinner, plus isophane at 2200 hr, use Table as guide to insulin adjustment, raising or lowering appropriate insulin by 2-4 units
- if patient usually using insulin analogue (e.g. lispro/aspart +/- glargine/detemir), additional isophane may be needed - discuss with diabetes team
DISCHARGE AND FOLLOW-UP
- Encourage early mobilisation
- Continue prophylactic LMWH until day of discharge (unless contraindicated)
- Check diabetes team have made appropriate follow-up arrangements or refer to diabetes team for out-patient review
- If patient new to insulin, prescribe needles for insulin pens, lancets and sharps guard