Management of Adult patients with Diabetic Ketoacidosis (DKA) & Hyperosmolar Non-ketotic Coma (HONK) Most current literature relevant to critical care

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1 NAME OF DOCUMENT TYPE OF DOCUMENT Management of Adult patients with Diabetic Ketoacidosis (DKA) & Hyperosmolar Non-ketotic Coma (HONK) GUIDELINE DOCUMENT NUMBER ED CLIN GL 04 DATE OF PUBLICATION May 2013 RISK RATING High LEVEL OF EVIDENCE Most current literature relevant to critical care REVIEW DATE May 2014 FORMER REFERENCE(S) Nil EXECUTIVE SPONSOR or EXECUTIVE CLINICAL SPONSOR Wendy Collis Divisional Co-Director Medicine and Emergency Medicine AUTHOR KEY TERMS SUMMARY Kham Saysana Diabetic Ketoacidosis (DKA) Hyperosmolar Non-ketotic Coma (HONK) To outline the early management of DKA and HONK in the Emergency Department.

2 Title Section 1 - Background... 3 Section 2 - Definitions... 4 Section 3 - Responsibilities... 5 Section 4 - Criteria for HDU / ICU Management... 6 Section 5 - Fluid Managment... 7 Section 6 - Insulin Therapy... 8 Section 7 - Potassium Replacement... 9 Section 8 - Other Therapies Section References Revision and Approval History REVISION: 0 Trim No: DT13/23017 April 2013 Page 2 of 11

3 Section 1 Aim Section 1 - Aim To outline the early management of DKA and HONK in the Emergency Department. REVISION: 0 Trim No: DT13/23017 April 2013 Page 3 of 11

4 Section 2 Definitions Section 2 - Definitions Definition: DKA Diabetes ketoacidosis is a condition associated with insulin deficiency resulting in hyperglycaemia and acidosis. Onset is usually over a few days. Diagnostic criteria include: BGL > 15mmol/L ph <7.15 HCO3 < 15mmol/L Positive serum/urine ketones (3+) Euglycaemic DKA can occur in: Pregnancy pre-hospital insulin recently administered reduce oral food intake Precipitating events include: Infection (Temp and WCC not helpful), new onset diabetes, poor compliance, acute abdomen (pancreatitis), alcohol, drugs, silent MI / CVA (older pts), steroids, and trauma. Main causes of death include: Aspiration (gastroperesis), hyper/hypokalaemia, cerebral oedema (extremely rare in adults, 0.3-1% in children). Definition: HONK Hyperosmolar non-ketotic coma is a condition with relative insulin deficiency resulting in significant hyperglycaemia and hyperosmolarity. Diagnostic criteria includes: >15 mmol/l (usually > 28) Osmolality >320 mosmol/l (2 x Na+ + G + Urea) No Significant acidosis (ph > 7.3 ; HCO3 > 15) Undiagnosed or known type II DM Usually no ketonuria Hypernatraemia in 50% pts +/- Decreased LOC / Confusion Precipitating events include: Infection, new onset diabetes, AMI, CVA and acute abdomen Main causes of death includes: Aspiration, pre-existing pathology, cerebral oedema REVISION: 0 Trim No: DT13/23017 April 2013 Page 4 of 11

5 Section 3 Responsibilities Section 3 - Responsibilities All staff are responsible for: Being familiar with and complying with ISLHD policies, procedures and guidelines. REVISION: 0 Trim No: DT13/23017 April 2013 Page 5 of 11

6 Section 4 Criteria for HDU / ICU Management Section 4 Criteria for HDU / ICU Management of DKA / HONK 1. Haemodynamic Instability 2. Inability to protect airway 3. Obtundation 4. Presence of abdominal distension or succussion splash (Acute gastric dilatation) 5. Insulin infusion or frequent monitoring of glucose / labs that can not be provided in ward Initial Evaluation / ABC Resuscitation bed Start IV Fluids Inform ED supervisor Early notification of admitting team / ICU Adjunctive investigations Finger prick BGL* Lab FBC / UEC / Osmolality / Lipase / Mg / PO4 / BHCG** / BC / Coags / ketone ABG / VBG ph / HCO 3 / Glucose / Lactate Urine U/A / MCS / Ketone / BHCG ECG, CXR Monitoring Vital signs Temp, PR, BP, SatO2 Glucose (VBG, ABG, finger prick) q1h K+, Lab glucose - q2h (X3), then q6h until normalisation of levels Ketones q4h until clearance Biochem (Na, HCO3, Cl) q4h until normalisation of Anion Gap*** Strict Fluid Balance Arterial BP, CVP when available Note: *finger prick glucose can be unreliable in dehydrated or hypothermic pts therefore lab glucose is good cross reference. Will read High at level > 32 **in females of child bearing age ***Anion Gap (AG) = Na (HCO3 + Cl), normal level 7-12 REVISION: 0 Trim No: DT13/23017 April 2013 Page 6 of 11

7 Section 5 - Fluid Management Section 5 Fluid Management NOTE: 1. CAUTION: Watch fluid overload in elderly / cardiac / renal patients Consider CVP 2. TWO venous access 3. If difficult iv access consider external jugular vein, intraosseous or central access 4. Fluid deficits = 5-10L are common in DKA and HONK 5. Colloid (Gelofusine/Haemacel) if no response to N/S 6. Monitor haemodynamics, hydration, and urine output N/Saline (0.9% Sodium Chloride) 1-2L in 1 st Hour THEN 500mls/h over next 2-4h THEN 0.45% Saline when circulation is stable Note: - Water deficit > Na deficit due to diuresis of half normal sodium content % Saline reduce risk of hyperchloraemic acidosis and non - AG acidosis - Aim to correct remaining fluid deficit gradually over next 24-48h - Availability - limited in ED, check with ICU / pharmacy - ALTERNATIVELY, 4% DEXTROSE & NS/5 CAN BE USED especially when BGL is below 15 Match with urine output (U/O) 0.45%Saline rate (ml/h) = U/O(ml/h) ml/h ADD 5% Dextrose when BGL <15 - At least 100g dextrose per 24h 80 ml/h if pt NBM Use 10% Dextrose if : - BGL <5.5 & Ketoacidosis persists (HCO 3 < 15) - Late pregnancy (twice more carbohydrate required) Continue dextrose until Ketones* or AG clearance & patient tolerating fluids PO *serum ketones(βoh) provide earlier and more reliable detection then urine ketones(acetoacetate, acetone) REVISION: 0 Trim No: DT13/23017 April 2013 Page 7 of 11

8 Section 6 Insulin Therapy Section 6 Insulin Therapy NOTE: 1. Withhold in pts with hypotension and severe BGL until BP improved with IV fluids 2. Withhold in pts with severe K + (<3.3) 3. Bolus not required 4. Check pump connections every hour and document residual volume 5. HONK pts may be very sensitive to exogenous insulin 6. Patients with SC insulin pump -safer to disconnect pump, start iv insulin -for mild DKA, interrogate pump/flow issue, -may discuss with endocrinologist 7. Monitor hourly BGL, fluid status Infusion: 50 units ACTRAPID in 50 mls 0.9% Saline via Syringe Pump ( 1 Unit / ml ) NB: Flush 10ml of solution through tubing before connecting to patient A Start Insulin infusion at 5 ml/h B Increase incrementally 1 ml/h(up to10 ml/h) IF no decrease in BSL of up to 4mmol/h in first 2h C Decrease to 3 ml/h when BGL <15 D INSULIN INFUSION RATE SLIDING SCALE (once BGL <15 or on initial presentation of euglycaemic DKA) Target: BGL mmol/l in 1 st 24hrs BGL Infusion Rate (Units/h) >20 5 E Taper Insulin & commence SC insulin when hyperglycaemia and ketoacidosis clears. In HONK pts, endpoint of treatment is based on normalisation of osmolality and regain of normal mental status. REVISION: 0 Trim No: DT13/23017 April 2013 Page 8 of 11

9 Section 7 Potassium Replacement Section 7 Potassium Replacement NOTE: 1. Initially, no K+ in first litre of NSaline 2. Exclude Hyperkalaemia 3. Ensure Urine output >30ml/hr 4. Generally KCL is given (consider other preparation to avoid excess Chloride) 5. Close cardiac monitor and infuse via central catheter if giving >0.5mmol/kg/h of K+ 6. Monitor q2h if K+ not in normal range Potassium replacement - K + >5 Nil K mmol/l in replacement fluid K mmol/l in replacement fluid or via separate infusion pump K + < mmol/l in replacement fluid or via separate infusion pump REVISION: 0 Trim No: DT13/23017 April 2013 Page 9 of 11

10 Section 8 Other Therapies Section 8 Other Therapies Consider: HCO3 replacement YES if ph < 6.9 (in setting of high K+ or arrhythmias or HCO3 5) NO if ph > 7 Heparin for HONK Note that large vessel arterial thrombosis and embolisation are common events Low dose heparin provided if no clinical evidence of thrombosis Hypo/HyperN+ Stabilize circulation with N/Saline Then discuss with supervisor about corrected Na+ (on repeated electrolyte) corrected Na+ = [(Glucose 10) 3] + apparent Na+ Phosphate / Magnesium replacement PO4< K2PO4 20mmol over 6 hours Mg<0.6 MgSO4 2g over 4h Oral forms also exist REVISION: 0 Trim No: DT13/23017 April 2013 Page 10 of 11

11 Section 9 - References Section 9 References 1. Magee MF, Bhatt BA. Management of decompensated diabetes Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar Syndrome. Critical Care Clinics V17, 1 (Jan 2001) 2. Kitabchi AE, etal. Treatment of diabetic ketoacidosis and hyperosmolar hyperglycaemic state in adults. UptoDate Kitabchi AE, etal. Hyperglycaemic Crises in Adult Patients With Diabetes. Diabetes Care, V32, 7, July 2009, Lebovitz HE. Diabetic ketoacidosis. The Lancet, V 345, March 25, Kwon KT, Tsai VW. Metabolic Emergencies. Emerg Med Clin N Am 25 (2007), Bull SV, etal. Mandatory protocol for treating adult patients with diabetic ketoacidosis decreases intensive care unit and hospital lengths of stay: Results of a nonrandomized trial. Critical Care Medicine V 35, No1 7. Kelly A-M. The case for venous rather than arterial blood gases in diabetic ketoacidosis. Emergency Medicine Australasia (2006) 18, Charles RA, etal. Point-of-care blood ketone testing: screening for diabetic ketoacidosis at the emergency department. Singapore Med J Nov 2007, 48(11): Goyal N, etal. Utility of initial bolus insulin in the treatment of diabetic ketoacidosis. J Emerg Med, May 2010; 38(4): Fu P, etal. Does potassium concentration measured on blood gas analysis agree with serum potassium in patients with diabetic ketoacidosis?. Emergency Medicine Australasia (2004) 16, Prince of Wales Hospital Policy & Procedure Committee. Insulin Infusion. South Eastern Sydney Illawarra, NSW Health, May 2007 (Internal only) 12. West Middlesex University Hospital. Diabetic Ketoacidosis / Hyperosmolar non-ketotic diabetic state. London. Oct 2009 (Internal only) 13. Shoalhaven District Hospital. Insulin Policy DKA / HONK. Illawarra area health service, Nov 2004 (Internal only) 14. Bersten AD, Soni N. Oh s Intensive Care Manual 6 th Ed. Butterworth Heinemann Hall J, etal. Principles of Critical Care 2 nd Ed. McGraw-Hill 1998 Revision and Approval History Date Revision no: Author and approval March Kham Saysana Reviewed at ED Leadership meeting-minor changes required (25 Feb 2013) Approved by ED Leadership group with minor change (25 Mar 2013) REVISION: 0 Trim No: DT13/23017 April 2013 Page 11 of 11