Tag Archives: diabetes

It’s a bit quiet in here

Blogging has slowed a bit as I’ve been travelling to the UK and am running courses here all week.

Just in case you’re desperate to read something useful, I came across a guideline on The Management of Diabetic Ketoacidosis in Adults by the Joint British Diabetes Societies Inpatient Care Group

The guideline contain the following approaches:

  • Measurement of blood ketones, venous (not arterial) pH and bicarbonate and their use as treatment markers
  • Monitoring of ketones and glucose using bedside meters when available and operating within their quality assurance range
  • Replacing ‘sliding scale’ insulin with weight-based fixed rate intravenous insulin infusion (IVII)
  • Use of venous blood rather than arterial blood in blood gas analysers
  • Monitoring of electrolytes on the blood gas analyser with intermittent laboratory confirmation
  • Continuation of long acting insulin analogues (Lantus® or Levemir®) as normal
  • Involvement diabetes specialist team as soon as possible

There is also a section on ‘Controversial Areas’, discussing such issues as bicarbonate therapy, rate of fluid therapy, and even 0.9% saline versus Hartmann’s (Ringer’s Lactate) solution, although this part was desperately disappointing, with the following bizarre excuse given for not recommending the latter:

In theory replacement with glucose and compound sodium lactate (Hartmann’s solution) with potassium, would prevent hyperchloraemic metabolic acidosis, as well as allow appropriate potassium replacement. However, at present this is not readily available as a licensed infusion fluid.

Apart from that, this appears to be an interesting and potentially useful document.

The Management of Diabetic Ketoacidosis in Adults
Joint British Diabetes Societies Inpatient Care Group

New Paediatric DKA guidelines

The International Society for Paediatric and Adolescent Diabetes (ISPAD) has published new comprehensive guidelines, including those for diabetic ketoacidosis.

Their summary:

• DKA is caused by either relative or absolute insulin deficiency.

• Children and adolescents with DKA should be managed in centers experienced in its treatment and where vital signs, neurological status and laboratory results can be monitored frequently

• Begin with fluid replacement before starting insulin therapy.

• Volume expansion (resuscitation) is required only if needed to restore peripheral circulation.

• Subsequent fluid administration (including oral fluids) should rehydrate evenly over 48 hours at a rate rarely in excess of 1.5 – 2 times the usual daily maintenance requirement.

• Begin with 0.1 U/kg/h. 1 – 2 hours AFTER starting fluid replacement therapy

• If the blood glucose concentration decreases too quickly or too low before DKA has resolved,
increase the amount of glucose administered. Do NOT decrease the insulin infusion

• Even with normal or high levels of serum potassium at presentation, there is always a total body deficit of potassium.

• Begin with 40 mmol potassium/L in the infusate or 20 mmol potassium/L in the patient receiving fluid at a rate >10 mL/kg/h.

• There is no evidence that bicarbonate is either necessary or safe in DKA.

• Have mannitol or hypertonic saline at the bedside and the dose to be given calculated beforehand.

• In case of profound neurological symptoms, mannitol should be given immediately.

• All cases of recurrent DKA are preventable.

Full guidelines available here
Other ISPAD guidelines available here