IntroductionDiabetic ketoacidosis (DKA) remainsa frequent and life threatening complication in type 1 diabetes. InEngland, more than 11% of peoplewith type 1 diabetes had an episodeof DKA in the years between 2004and 2009.1 Mortality rates have nowfallen significantly in the last 20 yearsfrom 7.96% to 0.67%.2 In 2010, theJoint British Societies Inpatient CareGroup developed and approvedguidelines on a weight-based, fixed-rate intravenous insulin infusion regimen for the management ofDKA in adults.3 These were based onthe systematic review of current evidence and accumulated profes-sional experience. Some changeswere made to these guidelines in2011,4 and they were introduced inSeptember 2012 at a hospital insouth east Wales. Junior doctors wereeducated about them in the educa-tional programmes and they are also available on the trust intranetbut were not a part of the junior doc-tor’s induction. These guidelineswere then audited on 24 patientsbetween October 2012 and March2013. Audit results obtained throughpersonal communication showed16% of the patients were not startedon the weight-based, fixed-rate regi-men. This led us to conduct a surveyon junior doctors’ knowledge ofthese guidelines.

AimsOur aims were to assess junior doctors’ knowledge of the weight-based, fixed-rate insulin regimen inthe management of DKA in adultsbased on the trust protocol.

MethodologyA survey was conducted on a randomday of a week in July 2013 at a hospi-tal in south east Wales. Data were collected by using a questionnaireconsisting of eight questions (see Box1) designed on the basis of the trustguidelines for DKA. This question-naire was distributed to junior doctorsworking on that day (house officers,senior house officers and registrars)in medical and surgical specialties inJuly 2013. Consultants were excludedfrom this survey as more often the initial management of DKA is done byjunior doctors. Data were analysed inMicrosoft Excel format.

ResultsThe questionnaire (Box 1) was dis-tributed to 56 junior doctors. A totalof 53 (95%) responses were receivedof which 34 were from medical doc-tors and 19 were from surgical doctors. The following results arenumbered in relation to the ques-tions posed in the questionnaire. 1. Thirty-five percent of medicaland 63% of surgical doctors werenot aware of the guidelines.

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Audit

Survey of junior doctors’ knowledge of the use of new guidelines in the management of diabeticketoacidosis in adults

AbstractDiabetic ketoacidosis (DKA) is a common medical emergency. In recent years a weight-based,fixed-rate intravenous insulin infusion regimen has replaced the conventional sliding scaleregimen for effective management of DKA. These guidelines have come into effect from 2012at a hospital in south east Wales.

A survey was conducted to assess the junior doctors’ (medical and surgical) knowledge ofthese guidelines as per trust protocol. The results of this survey clearly show that a significantnumber of doctors (35% of medical and 63% of surgical doctors) were not aware of theseguidelines; 15% of medical and 22% of surgical doctors were not aware of the criteria for thediagnosis of DKA. Copyright © 2014 John Wiley & Sons.

Practical Diabetes 2014; 31(2): 81–83

Key wordsdiabetic ketoacidosis; JBDS guidelines; knowledge; surgical doctors; medical doctors

Dr Preethi NallaMRCP, Specialist Registrar in Diabetes andEndocrinology, Royal Glamorgan Hospital, Llantrisant, UK

Dr Lokesh NukalapatiMRCPsych, Specialist Registrar in CAMHS (Child andAdolescent Mental Health Services), St David’sHospital, Cardiff, UK

Dr Deepan GosraniCT2 in Medicine, University Hospital of Wales, Cardiff, UK

Professor Peter J EvansMD, FRCP, Consultant in Diabetes and Endocrinology,Royal Gwent Hospital, Newport, UK

Correspondence to: Professor Peter J Evans, MD, FRCP, Consultant inDiabetes and Endocrinology, Royal Gwent Hospital,Cardiff Road, Newport NP20 2UB, UK; email: peter.evans7@wales.nhs.uk

Received: 25 November 2013Accepted in revised form: 17 December 2013

2. DKA is often misdiagnosed. Amultiple choice question was pre-pared on the criteria for the diagno-sis of DKA; 85% of medical and 78% of surgical doctors correctlyanswered the question.

3. Fluid replacement is a key thera-peutic intervention in the acutemanagement of DKA to restore cir-culatory volume, to clear ketonesand to correct the electrolyte imbal-ances. A question was developedusing the recommended fluid regi-men for the treatment of DKA basedon the trust protocol. A correctresponse was obtained from 55% ofmedical doctors and only 15% ofsurgical doctors.

4. Measurements of blood glucose,blood ketones and potassium are animportant part of the initial man-agement of DKA. Initially, bloodketones and blood glucose shouldbe measured hourly and potassium2 hourly. Only 58% of medical doctors and 29% of surgical doctorschecked them as per protocol.

5. Potassium replacement is essen-tial in the management of acuteDKA and inappropriate replace-ment could lead to life-threateningcardiac arrhythmias and increasedmortality. Only 20% of medical doc-tors and 5% of surgical doctorschose the appropriate replacement.

6. If the patient is on long-actinginsulin, then it is important for it tobe continued. This avoids reboundhyperglycaemia and ketogenesis,when switching from intravenousinsulin to subcutaneous insulin. Fifty-eight percent of medical doctors and21% of surgical doctors continuedthe long-acting insulin and stoppedthe short-acting insulin. Twenty-onepercent of medical doctors and 77%of surgical doctors stopped bothshort-acting and long-acting insulin.The rest of the medical and surgicaldoctors continued both short-actingand long-acting insulin.

7. Introduction of 10% dextrose isrecommended when blood glucosefalls below 14mmol/L to avoid hypo-glycaemia. Only 5% of medical doc-tors and 10% of surgical doctors used10% dextrose. Thirty-two percent of

82 PRACTICAL DIABETES VOL. 31 NO. 2 COPYRIGHT © 2014 JOHN WILEY & SONS

Junior doctors’ knowledge of the use of new guidelines in the management of DKA in adults

Audit

Circle the ONE correct answer in each question – as per new guidelines

Dr grade: ...................................................... Current specialty: .............................................

1. Are you aware of the new guidelines (fixed-rate insulin regimen) for diabeticketoacidosis (DKA)?

Yes/No

2. Diagnosis of DKA. Choose ONE of the following:

A. Blood glucose >20mmol, pH >7.3 / bicarbonate >20mmol, ketones <2mmolB. Blood glucose >11mmol, pH <7.3 / bicarbonate <15mmol, ketones >3mmolC. Blood glucose >20mmol, pH <7.3 / bicarbonate <15mmol, ketones <3mmolD. Blood glucose >30mmol, pH >7.3 / bicarbonate <15mmol, ketones 3mmol

3. If the diagnosis of DKA is confirmed, which fluid regimen do you give? (Presuming thereare no cardiovascular issues, elderly and young patients.) Choose ONE of the following:

A. N saline + KCl stat, N saline + KCl over 1 hour, N saline + KCl over 2 hoursB. N saline stat, N saline over 1 hour, N saline over 2 hoursC. N saline over 1 hour, N saline + KCl over 2 hours, N saline + KCl over 2 hoursD. N saline + KCl over 1 hour, N saline + KCl over 2 hours, N saline + KCl over 2 hours

4. When should you re-check blood glucose, ketones and K+? Choose ONE of thefollowing:

A. Blood glucose and ketones hourly and K+ 2 hourlyB. Blood glucose every 30 mins and K+ hourlyC. Blood glucose and K+ hourlyD. Blood glucose ketones and K+ 2 hourly

5. Which is the correct K+ replacement? Choose ONE of the following:

A. K+ level – 6.0 – 20mmol K+ per N salineB. K+ level – 5.0 – 40mmol K+ per N salineC. K+ level – 4.5 – 20mmol K+ per N salineD. K+ level – 3.0 – 20mmol K+ per N saline

6. If the patient normally takes insulin what should you continue? Choose ONE answer:

A. Stop both long-acting and short-acting insulinB. Stop short-acting insulin but continue long-acting insulinC. Continue both short-acting and long-acting insulinD. Stop long-acting but continue short-acting insulin

7. If the blood glucose falls to <14. Choose ONE answer:

A. Continue fixed-rate insulin until blood glucose <7B. Start a sliding scaleC. Give 5% dextrose along with N saline D. Give 10% dextrose

8. When would you stop fixed-rate insulin? Choose ONE answer:

A. Blood glucose within normal rangeB. pH >7.3, ketones <0.3 C. pH >7.35, ketones 1–2D. Bicarbonate <18, ketones <0.3

Box 1. Diabetic ketoacidosis questionnaire distributed to 56 junior doctors

medical and 15% of surgical doctorsused 5% dextrose along with normalsaline; 42% of medical doctors and11% of surgical doctors used the slid-ing scale. The remainder continuedon the fixed-rate regimen until theblood glucose falls below 7mmol/L.

8. Weight-based, fixed-rate insulin tobe stopped if pH is >7.3 and ketones<0.3mmol/L. The regimen should beconverted to a sliding scale regimenif the patient is not eating and drink-ing. Thirty-six percent of medicaldoctors and 14% of surgical doctorsstopped the fixed-rate insulin regi-men if the blood glucose was in thenormal range. Fifty-five percent ofmedical doctors and 21% of surgicaldoctors stopped it if the pH was >7.3 and ketones <0.3mmol/L. Theremainder stopped it if the pH was >7.35 and ketones were between1 and 2mmol/L.

DiscussionThis survey highlights the deficien-cies in the junior doctors’ knowl-edge regarding the new protocol for

the treatment of DKA and, further,compared the knowledge betweenmedical and surgical doctors. Theweight-based, fixed-rate intravenousinsulin infusion regimen in the man-agement of DKA clears ketonesfaster, thereby providing earlier resolution of DKA, better patientexperience and possible earlier dis-charge from hospital.5

Our survey clearly shows that thejunior doctors have poor knowledgeof these guidelines across medicaland surgical specialties. Medical andsurgical doctors clearly need moreeducational sessions. The results of

this survey will be displayed asposters on all wards and will be pre-sented in the educational sessions atthis hospital to increase the aware-ness of these guidelines. This hasnow become a part of the junior doc-tor’s induction.

We will aim to re-survey in sixmonths’ time after implementing allthese measures.

Declaration of interestsThere are no conflicts of interestdeclared.

References1. NHS Information Centre. National Diabetes

Audit 2008–2009. www.hscic.gov.uk/catalogue/PUB02577/nati-diab-audi-08-09-exec-summ.pdf[accessed 15 Sept 2010].

2. Lin SF, et al. Diabetic ketoacidosis: comparisons ofpatient characteristics, clinical presentations andoutcomes today and 20 years ago. Chang GungMed J 2005;28:24–30.

3. Joint British Diabetes Societies Inpatient CareGroup. The management of diabetic ketoacidosis in adults. www.bsped.org.uk/clinical/docs/dkamanagementofdkainadultsmarch20101.pdf.

4. Savage MW, et al. Joint British Diabetes Societiesguideline for the management of diabetic ketoaci-dosis. Diabet Med 2011;28:508–15.

5. Savage MW. Management of diabetic ketoacidosis,Clin Med 2011;11:154–6.

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Junior doctors’ knowledge of the use of new guidelines in the management of DKA in adults

Audit

Book review

l This survey identifies deficiencies injunior doctors’ knowledge of the newdiabetic ketoacidosis (DKA) protocolacross medical and surgical specialties

l It is important to increase theawareness of trust guidelines for bettermanagement of DKA in adults

l It clearly indicates junior doctors needmore educational input in this area

Key points

It was a pleasure reading throughthis book. It is a book I would

strongly recommend to my fellowdiabetologists, junior colleagues andmedical students who are interestedin attaining a better understandingof diabetes, as well as general practi-tioners, physicians, surgeons andhealth care professionals whoencounter patients with diabetesand diabetic complications.

The first comment to make isthat the book is easy to read. Thetext is broken down into bulletpoints and ‘take home messages’; itis therefore easy to navigate through

the text and comprehend the vari-ous concepts described.

Secondly, there is appropriateuse of multiple diagrams that sup-plement the information provided.For example, there are diagramssummarising the main features anddifferences between the variousforms of MODY, diagrams compar-ing and discriminating between thevarious features of type 1 versus type2 diabetes mellitus versus MODY etc.

Thirdly, I note the joint Europeanand American authorship; this isreflected in the text which containsinformation from studies, guidelines

and expert opinions from across bothsides of the Atlantic. Nevertheless,the usefulness of this book is by nomeans restricted to any specific geographical audience.

For UK specialist registrarspreparing for their endocrinologyand diabetes specialty exam (SCE),this book would assist in explainingthe principles and practices in thefield of diabetes mellitus. However,some of the fine details may differfrom existing guidelines, e.g. thecurrent diabetic ketoacidosis orsevere hypoglycaemia UK guidelinesare significantly different from thosedescribed in the book. One small‘grudge’ I had is that some of thedata quoted in the text are not verywell referenced.

Overall, this is a textbook worthacquiring, and it can prove to be aninvaluable tool to the multidiscipli-nary team members looking afterpeople suffering from diabetes.

Dr Angelos Kyriacou, ST7 in Endocrinology & Diabetes, UniversityHospital of South Manchester, UK

By David Leslie, M Cecilia Lansang, Simon Coppack and Laurence KennedyPublished 2012 by Manson Publishing (now CRC Press) 208 pages, price £40.00 hardbackISBN: 9781840761580 Website: www.crcpress.com

Diabetes: clinician’s desk reference