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Diabetic Ketoacidosis management update

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Diabetic Ketoacidosis management update

Text of Diabetic Ketoacidosis management update

  • 1. Diabetic Ketoacidosis A sweet new approach to an old problem
  • 2. Outline DKA background The new protocol Approaches in other hospitals
  • 3. What is it? Hyperglycaemia Ketosis and acidosis Dehydration Electrolyte imbalance
  • 4. Hyperglycaemia DKA is a state of insulin deficiency It is also a state of relative excess of glucagon and other hyperglycaemic hormones: catecholamines, cortisol, growth hormone etc This is likely to be triggered by conditions that result in one of these hormones being elevated Infection Pregnancy Medications (prescribed or non-prescribed) Trauma Burns
  • 5. Ketosis and acidosis Due to enhanced gluconeogenesis there is significant lipolysis Free fatty acids are metabolised into ketone bodies (acetoacetate and beta hydroxybutyrate) which accumulate Ketone bodies dissociate into ketone anions and hydrogen The bodies buffering capacity is exhausted leading to excess hydrogen ions
  • 6. Dehydration Osmotic diuresis Vomiting Third space
  • 7. Electrolyte imbalance Potassium One third will have K >5.5 All are potassium deplete (~300-600meq) Osmotic diuresis Sodium Increased osmolality dilutes extracellular sodium Osmotic diuresis causes increased extracellular sodium Phosphate Most will develop phosphate depletion but ?importance of this
  • 8. The context No hospital wide policy on DKA Unclear DKA proforma Ward to ward variations in practise
  • 9. The new model Standardised diagnosis Check for high risk criteria Standard fluid orders Fixed rate insulin dosing Maintain basal dose insulin
  • 10. Why the change? Wide variability makes assessment of outcomes difficult Cerebral oedema in children +/- young adults Pulmonary oedema Hypo/hyperkalaemia Hypoglycaemia
  • 11. Standardised diagnosis Fingerprick BSL and ketones Venous pH/gas unless hypoxic and/or ABG required Less emphasis on urine ketones
  • 12. High risk criteria Any of the following should prompt early senior input and NOSA/ICU review Ketones >6 Bicarbonate