INITIAL ASSESSMENT

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U B H T TEACHING CARE
DIABETIC EMERGENCIES CARE PROTOCOL AND CHART
INITIAL ASSESSMENT for DKA for underlying
cause urine ketones FBC Laboratory plasma
glucose Urine culture Arterial pH, PCO2,
PO2,HCO3 Blood cultures Urea and
electrolytes Pregnancy test ECG Chest X ray
Patient details or addressograph Name Address
Date of birth Ward
ASPECTS OF TREATMENT (to be addressed
simultaneously)

• B. Correction of ketoacidosis
• i.v. insulin ? 10 dextrose support until venous
  pH ? 7.3
• (See Chart 2, overleaf)
• aim for glucose fall 3-5 mmol/l/hr only
• do not give bicarbonate unless pH ? 6.9
  (registrar/consultant decision only)

A. Replacement of fluid and electrolyte
losses Normal saline ? KCl until hydration
restored (See Chart 1, overleaf)
C. Treat underlying cause
MONITORING AND CONTINUED CARE

• Biochemistry
• (one hour after starting
• treatment and 2 hourly
• until acidosis corrected)
• Venous pH
• plasma glucose
• Na,K,HCO3-
• Record results on Chart 3
• to measure venous pH, take venous blood sample
  into heparinized blood gas syringe and put
  through the blood gas machine

• Observations
• pulse and BP hourly
• notify Dr if pulse gt100/min or systolic BPlt100
  mmHg
• neuro obs. hourly if drowsy or reduced conscious
  level
• notify Dr if any deterioration in conscious level
  or increase in pupil size
• capillary blood glucose hourly
• fluid balance chart with hourly urine
• Ask the patient to pass urine every hour
  initially
• if has not passed urine after 2 hours
  catheterize.
• Withdraw catheter if good urine output after
  one hour
• contact Dr if hourly urine lt20 ml or lt30 ml/hr
  for two consecutive hours

• Other measures
• Nasogastric tube if vomiting and impairment of
  conscious level
• Coma management if indicated

• RECOVERY PHASE (This is when most problems
  occur)
• Continue IV regimen with infusion rate constant
  until acidosis corrected (pH ? 7.3), then
• if patient feels like eating give s.c insulin
  (6-8 units actrapid or patients normal dose) 30
  minutes before meal
• discontinue i.v. one hour after s.c. insulin
  given and meal eaten
• if patient still nauseated or anorectic
• continue 10 dextrose infusion (75ml/hr) with
  KCl and i.v. insulin at rate
• necessary to control blood glucose
• When patient eating and drinking normally
• Newly diagnosed Start twice daily Mixtard 30
  8-12 units b.d. and adjust dose as necessary
• Contact diabetes medical firm and specialist
  nurses for further management and education
• Known IDDM Recommence normal insulin and adjust
  as necessary. Consider temporary use of q.d.s.
  regimen if precipitating factor means that the
  patient is still unwell.
• Monitor with capillary blood glucose and urine
  testing for ketones before meals and bedtime

MOST COMMON ERRORS IN THE MANAGEMENT OF DIABETIC
KETOACIDOSIS 1. The insulin pump is not connected
to the patient 4. Loss of continuity or
attention in the recovery phase 2. Failure to
review fluid replacement, particularly in the
elderly 5. Stopping i.v. insulin before s.c.
given 3. Failure to act on results (e.g serum
potassium) 6. Failure to identify the underlying
cause
In event of very severe DKA, problems or queries
about management, call a consultant diabetologist
(via switchboard)
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CHART 1 FLUID AND ELECTROLYTE REPLACEMENT
USUAL ADULT REQUIREMENT Normal saline (0.9) -
1 litre in first 30 min - 1 litre in next
hour -Review - Continue saline infusion until
hydration restored (with simultaneous dextrose
infusion if indicated) Potassium lt3.5 mmol/l
40 mmol/l KCl 3.5-5.5 mmol/l 20 mmol/l gt5.5
mmol/l Stop KCL STOP KCl IF THE PATIENT IS
ANURIC (Aim to keep K in the range 4.0 - 5.5
mmol/l)
Do not give bicarbonate unless pH ? 6.9. If
necessary use 1.4 solution 20 mmol KCL. Always
discuss with Registrar or Consultant before
giving HC03 . Refractory acidosis may result
from inadequate fluid and electrolyte replacement.
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Chart 2 CORRECTION OF KETOACIDOSIS GLUCOSE AND
INSULIN INFUSIONS
If BG has risen since the last measurement,
inspect pump, cannula and all connections
- this problem is always caused
by insulin not actually getting into the patient
Contact Dr if blood glucose falls more than
10 mmol/l in one hour blood glucose has risen
since the last measurement and the pump and all
connections are intact
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Chart 3 LABORATORY RESULTS
Initial investigations For DKA For underlying
cause Plasma glucose FBC Arterial blood
gases Urine culture Urea, electrolytes,
HCO3- Blood cultures ECG Pregnancy
test (urine ?HCG) Chest X ray
Monitoring One hour after starting treatment and
2 hourly until acidosis corrected Venous pH
Laboratory plasma glucose Na, K, HC03-
Contact Dr if Venous pH lt7.30 and has not
risen since last measurement Plasma glucose
falls by more than 10 mmol/l per hour, or if
plasma glucose is above 15 mmol/l and has not
fallen over 2 hours Na lt130 or gt 155
mmol/l K lt3.5 or gt5.5 mmol/l
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