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Are We Adhering to Recommended Guidelines?

Abstract and Introduction

Abstract

Introduction: Diabetic ketoacidosis (DKA) is an acute complication of diabetes mellitus that requires prompt

treatment. However delays in treatment are common and can have serious consequences. Local guidelines state all

patients with DKA should receive intravenous fluids within 60 minutes. This audit series establishes if there is local

adherence to this guideline.

Methods: In total 111 cases were audited over four consecutive years. Case notes were identified retrospectively by

clinical coding and notes were reviewed to establish the time between arrival to Accident and Emergency and

administration of intravenous fluids.

Results: In 2008, 17 of 29 patients who attended Accident and Emergency with DKA received intravenous fluids as

per the guideline, 11 of 24 patients in 2009, 17 of 28 patients in 2010 whilst in 2011 20 of 27 patients received fluids

as recommended.

Discussion: Although this audit found that there have been improvements in administration of prompt intravenous

fluids at Whittington hospital, there are still patients who do not receive this treatment as recommended. It remains to

be seen if the introduction of bedside ketone testing will facilitate a speedier diagnosis and therefore more timely

initiation of intravenous fluids.

Introduction

DKA is an acute metabolic complication of diabetes mellitus characterised by ketonaemia, metabolic acidosis and

dehydration. Aretaeus of Cappadocia described the profound dehydration in DKA in the second century BC: 'thirst

unquenchable, drinking excessive … their mouths become parched and their bodies dry; the viscera seem scorched

up … and within a short time, they expire.' The typical total body fluid deficit in a patient presenting with DKA is 6 l.[1]

Despite rising knowledge and awareness of this condition, DKA continues to have a significant mortality. The 1999

British Diabetic Association Cohort Study showed 54% of diabetes related deaths in men and 76% of diabetes

deaths in women were due to DKA.[2] The age-adjusted death rate for diabetic hyperglycaemic crisis in the USA in

2005 is calculated as 0.8 per 100,000 of the general population.[3] Hyperglycaemia is a common feature, but

normoglycaemic DKA has been described.[4]

DKA is a medical emergency that requires prompt treatment. The cornerstone of treatment in DKA is replacing the

fluid deficit with rapid intravenous fluid and correcting the ketoacidosis with intravenous insulin. Delays in treatment

can lead to significant complications and death.[5] Successful management relies on early recognition and treatment

by the emergency and acute medical teams. Unfortunately delays in diagnosis and treatment, particularly in

administration of intravenous fluids, are not uncommon. Published studies are variable, ranging from 31% to 80% of

patients receiving appropriate intravenous fluids within 60 minutes of attendance to the emergency department.[6,7]

One US study showed that even with the relaxed target of appropriate fluid resuscitation of 8 hours, and after the

introduction of a local guideline, 12% of patients were not fluid resuscitated adequately.[8]

The Joint British Diabetes Societies, supported by NHS Diabetes, published national guidelines on the acute

management of DKA in March 2010 (). These guidelines advise on the management once the diagnosis of DKA has

Fluid Management in Diabetic Ketoacidosis

Robert Freudenthal, Nicola Tufton, Christine Podesta, Rebecca Mulholland, Michela Rossi

British Journal of Diabetes and Vascular Disease. 2013;13(3):138-142.

been made and recommend immediate fluid administration; however, they do not suggest a target of time to arrival to

the emergency department to the initiation of intravenous fluids.[9] Many acute hospitals have also established local

guidelines to assist acute medical and emergency teams in managing patients with diabetic ketoacidosis with

variable success. Whittington Health NHS Trust first introduced a guideline in 2006 with a target of administering

intravenous fluids within 60 minutes of attendance to the emergency department. The guideline has been promoted

and updated with yearly education sessions to acute medical staff. Regular audits have been conducted to ascertain

if the guidelines are being adhered to and if the target of all patients with DKA receiving intravenous fluids within 60

minutes of attendance is met.

Table 1. Immediate management of diabetic ketoacidosis in adults.9

Diagnostic criteria: all three of the following must be present

•capillary blood glucose above 1L mmol/L

•capillary ketones above 3 mmol/L or urine ketones ++ or more

•venous pH less than 7.3 and/or bicarbonate less than 15 mmol/L

Action 1: initiate 0.9% sodium chloride solution using following regime:

•500ml over 10–15 minutes if systolic blood pressure is below 90 mmHg. Repeat and request senior input if

systolic blood pressure remains less than 90 mmHg.

•Once systolic blood pressure is greater than 90 mmHg, give 1L over first 60 minutes

•1L with potassium chloride over next 2 h

•1L with potassium chloride over next 2 h

•1L with potassium chloride over next 4 h

•add 10% glucose 125 ml/h if blood glucose falls below 14 mmol/L

Action 2: commence fixed rate intravenous fast acting insulin of 0.1 units/kg/h based on an estimation of the

patient's weight

Action 3: assess patient with full set of observations including Glasgow Coma Score and full clinical examination

Action 4: further investigations, including venous glucose, renal function, full blood count, blood cultures,

electrocardiogram, chest radiograph and urine culture

Action 5: establish monitoring system, including hourly capillary blood glucose, hourly capillary ketone

measurement if available and venous bicarbonate and potassium at 60 minutes, 2 h and 2 hourly thereafter, and 4

hourly plasma electrolytes. Consider continuous cardiac monitoring and pulse oximetry if appropriate.

Action 6: consider and treat potential precipitating complications

Methods

Four audits have been carried out in order to assess adherence with the local audit standard of 100% patients with

DKA receiving intravenous fluids within 60 minutes of attendance to the emergency department. The audit has been

carried out every year from 2008 with a total 111 patient episodes of DKAs audited.

Whittington Health NHS Trust uses a clinical coding system based on the diagnosis written on the patient's

discharge summary by the discharging clinician. Cases of DKA were identified with the assistance of the medical

records department. In each year audited, all clinical patient cases which received a coding diagnosis of DKA, HHS,

or hyperglycaemia and were above the age of 18 at time of admission were reviewed. In order to verify that the coding

diagnosis was accurate, the medical notes were reviewed, and the patient would be included if they met the criteria of

diagnosis as described in local guidelines. There were three criteria: capillary blood glucose to be greater or equal to

10 mmol/L, positive urine ketones, and acidosis identified by either bicarbonate less than or equal to 15 mmol/L or a

pH less than or equal to 7.3. All three criteria had to be met for the patient to be included in the audit analysis.

Exclusion criteria from the audit were either where patients did not meet the criteria for diagnosis, or where it was not

possible to locate case notes. Every DKA episode was audited. The total number of patients included and excluded

for each year is demonstrated in .

Table 2. Audit exclusion criteria.

  2008 2009 2010 2011

Patients with discharge diagnosis of DKA 53 56 44 47

Excluded after review of case notes (did not meet DKA criteria) 24 32 14 17

Case notes unable to be located 0 0 1 3

Included in audit 29 24 29 29

The auditing team reviewed the case notes to establish what time the patient arrived at the emergency department.

Time of arrival was taken as the time the patient booked into the emergency department reception. The drug chart

was reviewed to ascertain how long after arrival (in minutes) the patient's intravenous fluids were first administered.

Other information was also collected, including the time to administration of insulin, which initial investigations were

performed, the length of admission, if basal subcutaneous insulin was continued whilst on an intravenous infusion, if

hourly capillary blood glucose monitoring took place, if any clear precipitant to the DKA episode was documented, if

the patient had a known diagnosis of diabetes and the demographic qualities of each patient including age and

ethnicity. Data were input into Microsoft Access software.

Results

The number of patients each year with corresponding percentage that received the intravenous fluids within 60

minutes of attendance to the emergency department is displayed in .

Table 3. Initial treatment and monitoring in patients arriving to the emergency department.

Year 2008 2009 2010 2011

Received intravenous fluids within 60

minutes

17

(58.6%)

11

(45.8%)17 (60.7%) 20 (74.1%)

Received insulin within 60 minutes21

(72.4%)

7

(29.2%)13 (46.4%) 13 (48.1%)

Received hourly capillary blood

glucose monitoring

22

(75.9%)

20

(83.3%)26 (92.9%) 27 (100%)

Mean time to administration of

intravenous fluids (min)62 62 55 56

Median time to administration of

intravenous fluids (min)46 75 45 37

Range of times to administration of

intravenous fluids (min)0–236 12–215 0–123 0–220

28 (1 set of notes had 27 (2 sets of notes had

Total number of patients audited 29 24 incomplete fluid data) incomplete fluid data)

Length of admission varied considerably between years and within each yearly data set. In 2011 alone 13 patients

were admitted for 1 or 2 days, but three patients had an admission of greater than 10 days. The expansion of

ambulatory care, the increasing impact of early discharge teams and the restructuring of social care within the local

catchment area across this time period makes meaningful comparisons of admission length challenging and is

beyond the scope of this audit.

The proportion of patients that had a known diagnosis of diabetes varied significantly over the different audit periods ().

Table 4. Proportion of admissions with known diabetes.

  2008 2009 2010 2011

No previous diagnosis of diabetes 5 (17%) 6 (25%) 7 (24%) 5 (17.2%)

Known patient with diabetes 24 18 22 24

Total number audited 29 24 29 29

Discussion

DKA is a medical emergency and prompt recognition and treatment is essential to providing good quality care.

Nevertheless the findings of this series of audits are consistent with other published data and clearly illustrate that

significant barriers remain in ensuring the prompt treatment of DKA.[6] Prompt treatment of other medical

emergencies have also faced similar difficulties. A national audit of adherence to a target of patients with neutropenic

sepsis receiving intravenous antibiotics within 60 minutes of attendance to the emergency department showed that

just 26% of patients received antibiotics within the target time, with some patients experiencing delays of over five

hours.[10]

Following the results of the audit in 2008, which illustrated poor adherence to local guidelines with only 58.6%

patients meeting the 60 minute target, the diabetes team at the Whittington initiated yearly education sessions for

junior staff and introduced an easily accessible guideline. This included a single sheet protocol that should be printed

and placed in the patient's notes and which includes a table within which to write blood results for ongoing

management, to improve continuity of care within the hospital shift systems and at handover meetings ().

Table 5. DKA flowchart to be printed out and completed during admission.

Keep in Obs folder then file in notes on discharge.

Name:_______________

Hospital number:_______

Date of birth:__________ Date:__________

Measure CBG hourly. NB if bedside meters registers 'HI' or '>20' venous blood must be sent to laboratory for

analysis or measured via Blood Gas Analyser

Measure pH, bicarbonate and K+ at 1 hour & 2 hours then 2 hourly for 6 hours or longer until pH>7.3 and K+ within

normal range

Hour post admission: 00 01 02 04 06 08 10 12 14 16 18 20 22

Biochemical results

pH

Plasma bicarbonate

K+

Plasma glucose or CBG

Remember to stop fixed rate insulin infusion & convert back to insulin sliding scale when pH>7.3 &/or bicarbonate

>18 mmol/L.

The results of this series of audits shows that there have been considerable variation in the number of patients that

receive intravenous fluids within the target time, with 45.8% of patients meeting the target in 2009, but 74.1% of

patients receiving fluid within the recommended time in 2011. There has been overall improvement since introduction

of a local guideline; with the most recent audit from 2011 having the highest yet proportion of cases meeting the

target. Further research must be done to establish whether certain patient characteristics, such as having previously

undiagnosed diabetes, place them at a greater risk of having delayed initiation of fluids. It would also be useful to do

further investigation to ascertain which staff factors, for example seniority and experience of the admitting team,

influence the delay in initiation of DKA treatment.

The acute initial phase of DKA is mostly managed by acute medical and emergency staff. The rapid changeover of

these teams means that ongoing training and repeat sessions to introduce staff to the DKA guidelines and targets for

treatment are essential if the proportion of cases receiving treatment is to be improved upon. Further research and

audit will need to be carried out once capillary ketone testing is introduced in order to establish if this functions as an

aid to a quicker diagnosis.

Sidebar

Key Messages

1. DKA is a medical emergency, characterised by ketonaemia, dehydration and metabolic acidosis

2. Typical total body fluid deficit in patients. presenting with DKA is 6 litres.

3. Rapid intravenous fluid administration is a priority and should be initiated as soon as possible.

4. Delays in diagnosis and initiation of intravenous fluids are common.

5. Delays in treatment can have serious complications including death.

6. Typical total body fluid deficit in patients presenting with DKA is 6 litres.

References

1. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic Crises in Adult Patients With Diabetes.

Diabetes Care 2006; 29: 2739–2748.

2. Laing SP, Swerdlow AJ, Slater SD et al. The British Diabetic Association cohort study, II: cause-specific

mortality in patients with insulin-treated diabetes mellitus. Diabet Med 1999;16: 466–71.

3. Centers for Disease Control and Prevention. Diabetes data and trends.

http://www.cdc.gov/diabetes/statistics/mortalitydka/fRateDKAGenAgeAdjusted.htm (Accessed June 20,

2013).

Acknowledgments

We wish to acknowledge all those that assisted in auditing: Jason Cheung, Richard Fish, Kalyan Gurazada, ArifHamda, Neil Hill, Laura Kelly, Teresa Tang and Jules Waung.

Abbreviations

DKA diabetic ketoacidosis; HHS hyperosmolar hyperglycaemic state

British Journal of Diabetes and Vascular Disease. 2013;13(3):138-142. © 2013 Sage Publications, Inc.

4. Clark JD, McConnell A, Hartog M. Normoglycaemic ketoacidosis in a woman with gestational diabetes. Diabet

Med 1991; 8: 388–9.

5. Bird S. Failure to diagnose: diabetic ketoacidosis. Aust Fam Physician 2010; 39: 867–8.

6. Singh RK, Perros P, Frier BM. Hospital management of diabetic ketoacidosis: are clinical guidelines

implemented effectively? Diabet Med 1997; 14: 482–6.

7. Devalia B. Adherance to protocol during the acute management of diabetic ketoacidosis: would specialist

involvement lead to better outcomes? Int J Clin Pract 2010; 64: 1580–2.

8. Llag LL, Kronick S, Ernst RD et al. Impact of a critical pathway on inpatient management of DKA Diabetes

Res Clin Pract 2003; 62: 23–32.

9. Joint British Diabetes Societies supported by NHS Diabetes. The Management of Diabetic Ketoacidosis in

Aduls. http://www.diabetes.org.uk/About_us/Position-statements--recommendations/Care-

recommendations/The-Management-of-Diabetic-Ketoacidosis-in-Adults, March 2010. (Accessed 20 June

2013).

10. Clarke RT, Warnick J, Stretton K, Littlewood TJ. Improving the immediate management of neutropenic sepsis

in the UK: lessons from a national audit. Br J Haematol 2011; 153: 773–9.