Diabetic ketoacidosis (DKA) though preventable remains a frequent and life threatening complication of type 1 diabetes. Unfortunately, errors in its management are not uncommon and importantly are associated with significant morbidity and mortality.
Most acute hospitals have guidelines for the management of DKA but it is not unusual to find these out of date and at variance to those of other hospitals. Even when specific hospital guidelines are available audits have shown that adherence to and indeed the use of these is variable amongst the admitting teams.
These teams infrequently refer early to the diabetes specialist team and it is not uncommon for the most junior member of the admitting team, who is least likely to be aware of the hospital guidance, to be given responsibility for the initial management of this complex and challenging condition.
To address these issues the Joint British Diabetes Societies, supported by NHS Diabetes has produced up-to-date guidance developed by a multidisciplinary group of practicing specialists, with considerable experience in this area. Where possible the guidance is evidenced based but also draws from accumulated professional experience.
A number of new recommendations have been introduced including the use of bedside ketone meters (though management based on bicarbonate and glucose are retained for those yet to introduce ketone meters), the use of fixed rate intravenous insulin infusion, and mandatory and prompt referral to the diabetes specialist team in all cases.
The management is clearly presented and divided into a number of key steps in the care pathway; the first hour, the next six hours, next twelve hours etc. Importantly, conversion to subcutaneous insulin and preparing for discharge home are included. Audit is encouraged against defined standards.
The guideline is clearly written and accompanied by a practical and easy to follow flow chart to be used in admitting departments and wards managing DKA.
These guidelines are recommended to all diabetes hospital teams for rapid introduction and for acceptance as the national guideline for managing DKA. Their widespread introduction should significantly improve the care of people admitted with DKA.
March 2010