Please inform the Diabetes Nurse Specialist that this patient has been admitted within 24hrs of admission.

Transcription

1 Adult Diabetic Ketoacidosis Care Bundle (V1. Issued October 2014 Review October 2015) Improving patient care This pack includes: DKA Management Guideline Name: (Patient Addressograph) DOB: Hospital No: A DKA pack has been commenced for this patient on / / DKA Care Pathway Monitoring Sheet DKA Fluids Chart DKA Discharge care bundle DIAGNOSIS of DKA Ketonaemia >3.0mmol/l(POCT) (++ on standard urine stick) BG >11.0mmol/l or known diabetes HCO 3 - <15.0 mmol/l and/or Venous ph < Diabetic Ketoacidosis Care Bundle Audit slip A DKA pack has been commenced for this patient on / / Name: (Patient Addressograph) DOB: Hospital No: Please inform the Diabetes Nurse Specialist that this patient has been admitted within 24hrs of admission. Please return this slip to Diabetes team secretary (via the ward clerk - internal post). Thank you. 1 PRO-P /15 1

2 List of Abbreviations: ASAP As soon as possible ITU Intensive Therapy Unit BP Blood Pressure IV Intravenous BG Blood Glucose IVII Intravenous Insulin Infusion CRP C-reactive protein K + Potassium CXR Chest X-ray KCl DKA Diabetic Ketoacidosis L / l Litre / litre DR Doctor MSU Midstream Specimen of Urine DSN Diabetes Specialist Nurse NaCl ECG Electrocardiogram NG Naso-gastric FBC Full Blood Count POCT Point of Care Test FRIII Fixed Rate Insulin Intravenous Infusion SBP Systolic Blood Pressure GCS Glasgow Coma Scale SC Subcutaneous HCO 3 - Bicarbonate U&E Urea and Electrolytes HDU High Dependency Unit LMWH Low Molecular Weight Heparin IM Intramuscular VRII Variable Rate Insulin Intravenous Infusion I/O Input / Output 2 PRO-P /15

3 Diabetic Ketoacidosis Management Guidelines (October 2014) Adapted from JBDS In-Patient Care Group Guidelines (2013) Initial investigations: Ketone/ BG readings FBC, U&Es, glucose, CRP Venous gases Blood cultures CXR, ECG, Weight Urinalysis +/- MSU IV fluid resuscitation: Standard regimen: - 1L NaCL / 1 hour over 1 st hour - 1L NaCL + KCL over next 2 hours - 1L NaCL + KCL over next 2 hours - 1L NaCL + KCL over 4 hours - 1L NaCL + KCL over 4 hours - 1L NaCL + KCL over 6 hours Re-assess at 12 hours (mandatory), further fluid may be required. Avoid K + replacement with initial resuscitation (prerenal failure) Give 40mmol/L maintenance KCL if K mmol/L Commence fixed rate Intravenous Insulin Infusion (FRIII): 50 units Actrapid (made up to 50ml with sodium chloride) 0.1unit/kg/hour. Prescribe 10% IV glucose (125mls/hour) to commence if BG <14mmol/l alongside NaCL Ensure long-acting Insulin analogues (e.g. Lantus) are continued with IVII If SBP <90mmHg give 500ml fluid challenge (NaCL ) over minutes. If BP responds, follow standard fluid replacement regimen (caution in elderly). Repeat fluid challenge again if BP still <90mmHG. If no response involve ITU/ critical care team. Transfer to HDU if K + <3.5mmol/L Aim for in blood ketones by 0.5mmol/L/hour if not, after 1 hour, increase IVII by 1 unit/hour increments until achieved. - permits the continuation of a fixed rate IVII to suppress ketogenesis. - Avoids rebound hyperglycaemia when IVII is stopped Establish monitoring regimen: Hourly ketone/ BG levels 2 hourly serum K +, venous ph and bicarbonate (for first 6 hours) Regular observations (hourly) inc. GCS - (if <12 transfer to ITU/ critical care) Consider catheter if anuric/ incontinence at 60 mins to enable I/O monitoring Cardiac monitor if severe Consider NG tube if severely obtunded/ persistent vomiting to prevent aspiration Continue fixed rate Intravenous Insulin Infusion (FRIII) until: ketones <0.6 mmol/l (venous ph >7.3 and/or bicarbonate >18 mmol/l) At 12 hours, repeat bloods. Patient should aim to be If not eating and drinking and ketonaemia has resolved; eating and drinking. move to sliding scale as per Diabetes Medication Chart. Transfer to SC Insulin (e.g. Novorapid) with a meal and stop IVII one hour later. Refer to specialist diabetes team at earliest opportunity (within first 24hrs). Full guidelines available at: PRO-P /15 3

4 DKA Care Pathway (To be used in conjunction with DKA management protocol) * Upon presenting to hospital (ACDU/ A&E triage or Out of Hours GP) type 1 diabetes who are unwell should immediately have their blood glucose level checked * Addressograph: BG 11 Complete full set of observations: - Pulse - GCS - BP - Oxygen saturations - Temperature - Respiratory rate Inform on call Dr of patient s admission If severe DKA suspected, call senior doctor immediately: - ph <7.0 - Blood Ketones >6 mmol/l - GCS <12 - Hypokalaemia (<3.5 mmol/l) - SBP <90 mmhg - Bicarbonate <5 mmol/l - Pulse>100 or <60bpm - Anion gap >16 [Anion Gap = (Na + + K + ) (Cl - + HCO 3-] At 1 hour ensure the following have been done: (tick all that apply) Observations POCT BG + ketones Clinical assessment & examination by Dr IV cannulation & commence fluid resuscitation ( NaCl) 60 minutes 6 hours: (tick all that apply) Measure and chart hourly ketones & BG (if HI send serum glucose) Weigh patient/ or estimate if unable (in kg) Bloods, blood cultures and venous gas (ph, K+) ECG, CXR, urine dipstick & MSU Start fixed rate IVII via infusion pump - only give a stat IM dose if delayed (0.1 unit/ kg) If ketones are not falling by 0.5 mmol/l/hr increase IVII rate by 1 unit/ml/hr until achieved Continuous cardiac monitoring & pulse oximetry Consider precipitating causes and treat Refer patient to DSN ASAP Ensure usual medication for diabetes is prescribed * Continue Lantus/ Levemir/Degludec with IVII. If dose unknown seek advice from the Diabetes Team Maintain serum K+ in the normal range ( mmol/l) Catheterise if incontinent/ anuric LMWH prophylaxis Consider NG tube if obtunded/ vomiting ++ Measure venous gas for ph, HCO 3, K+ at 60 mins, 2, 4, 6 and 12 hours hours: continue regime, assess for complications and avoid hypoglycaemia. If DKA resolves (ketones <0.6 mmol/l, ph > 7.3) ~ hours):- I/O chart accurate fluid balance monitoring If BG < 14mmol/L, commence 10% glucose at 125mls/ hr alongside fluids A. Transfer to SC insulin with a meal if patient is eating and drinking and stop IVII after an hour. B. If patient is not eating and drinking move to sliding scale and document change on chart. 4 PRO-P /15

5 DKA Monitoring Chart Name: DOB: / / Hospital No: Date Time Glucose>30 specify x Ketone Level (mmol/l) Glucose level (mmol/l) Glucose (mmol/l) Ketones (mmol/l) Insulin (units/h) Total Insulin infused (ml) Syringe vol remaining (ml) IV Glucose 10% rate (ml/h) Registered Nurse Sig. Recorder Band Other Metabolic Parameters: Potassium ph Bicarbonate Urine Output (mls/h) PRO-P /15 5

6 PATIENT S NAME... HEALTH RECORD NUMBER... ADULT DIABETIC KETOACIDOSIS MANAGEMENT (Use according to DKA guidelines) Caution in elderly/ccf Cancel IV infusion if not required. PHARM DATE START STOP Date Infusion Fluid Volume Route Medicine Added Infusion Rate Pres Sig TIME VOL GIVEN GIVEN BY CH KD BY 1L IV 1 hour 2 hours 2 hours 4 hours 4 hours 6 hours Glucose 10% 1L IV Commence with fluids * If BM < 14mmol/L* 125ml per hour Made up to 50ml IVII 50 units Actrapid 0.1 unit/kg/hr Rate..ml/hr 6 PRO-P /15

7 Guidance Notes on using DKA fluids chart Risk of fluid overload in elderly or where history of chronic kidney disease or congestive cardiac failure, monitor for signs of fluid overload and amend rates of infusions accordingly Otherwise Risk of inadequate fluid replacement if rates of fluid replacement not achieved and monitored according to protocol For some patients more aggressive fluid replacement may be indicated Most likely Potassium replacement will be required as charted. Monitoring of electrolytes essential with replacement according to protocol monitored: Measure electrolytes: 2 hourly from 0-6hours Repeat at 12 and 24 hours K + in first 24 hrs K + replacement > 5.5 Nil mmol/l < 3.5 Senior review/hdu Cancel IV potassium chloride if not required and take appropriate additional action where <3.5 10% Glucose infusion is continuous and in addition to once BG falls below 14mmol/L Start insulin early as detailed in protocol PRO-P /15 7

8 PATIENT S NAME....HEALTH RECORD NUMBER... DKA Discharge Care Bundle Improving patient care The discharge care bundle Summary This care bundle should be delivered to all patients being discharged from hospital following an admission for DKA. The care bundle aims to improve quality of care and patient experience. It also aims to reduce the risk of readmission. Verbal information given: (tick if given) Blood glucose monitoring Date: / / Sig... Hypo/Hyperglycaemia Date: / / Sig... Ketone testing Date: / / Sig... Sick day rules Date: / / Sig... Patient education assessed for suitability: (tick if yes) Patient Education Course anticipated date: Written patient information given: (tick if given) Safe and effective use of insulin: (tick if given) Insulin Passport: (tick if given) Date: / / Sig... Date: / / Sig... Date: / / Sig... Outpatient follow up appointment made and given to patient: Diabetes Nurse Specialist: Date: / / Sig... or Clinic appointment agreed: Date: / / Sig... or Practice nurse: Date: / / Sig... 8 PRO-P /15