Management of diabetic ketoacidosis following implementation of the JBDS guidelines: Where are we and where should we go?

Crasto, Winston; Htike, Zin Zin; Turner, Lisa; Higgins, Kath

doi:10.15277/bjdvd.2014.040

Cited by 24 publications

(28 citation statements)

References 11 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Crasto et al who found that their median time to developing hypoglycaemia (just under 12.9 hours) was after their median time to resolution (12.1 hours), suggesting that the intravenous insulin infusion was used for too long [2]. In the present study, there was no relationship between developing hypoglycaemia and not getting 10% dextrose when the blood glucose dropped below 14mmol/l.…”

Section: Hypoglycaemiacontrasting

confidence: 41%

“…It is a common experience among clinicians that much of the in hospital morbidity experienced by patients is related to DKA treatment, and that there is wide variability in the definition of DKA and use of guidelines between teams. To date, there has only been one study that looked in detail at DKA outcomes that mapped outcomes against a standardised guideline [2].…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

National survey of the management of Diabetic Ketoacidosis (DKA) in the UK in 2014

et al. 2015

View full text Add to dashboard Cite

2 Novelty Statementa) In 2013 a revised version of national guidance on the management of DKA was published, however there are no data to show that these recommendations actually work b) This is the largest national survey on the management of DKA c) Most patients developed hypokalaemia and over 25% developed hypoglycaemia. There were also significant issues with care processes d) The management of DKA will need to change to prevent hypokalaemia but will necessitate a shift in where patients are cared for. However, as a result of moving to a High Dependency or Intensive Care environment, care processes may improve.3 Abstract AimsOutcomes for the management of diabetic ketoacidosis (DKA) remain largely unstudied. In a national survey we examined outcomes of adult patients presenting with DKA in 2014, mapped against accepted UK national guidance. MethodsData were collected in a standardised form covering clinical, and biochemical, outcome, risk, and discharge planning. The form was sent to all UK diabetes specialist teams (n=220). Anonymised data were collected on 5 consecutive patients admitted with DKA between 1.5.14 and 30.11.14 Results 283 forms were received (n=281 patients), from 72 hospitals, 71.4% used the national guidelines. 7.8% of cases occurred in existing inpatients. 6.1% of admissions were newly diagnosed diabetes. 33.7% of patients had had at least 1 episode of DKA in the preceding year. The median time to starting 0.9% sodium chloride and intravenous insulin was 41.5 minutes and 60 minutes respectively. Median time to resolution was 18.7 hours, and median length of hospital stay was 2.6 days. Significant adverse biochemical outcomes occurred; with 27.6% of patients developing hypoglycaemia and 55% reported hypokalaemia. There were also significant issues with care processes.Initial nurse led observations were well carried out, but subsequent patient monitoring remained suboptimal. Most patients were not seen by a member of 4 the diabetes specialist team during the first 6 hours, but 95% were seen before discharge.A significant minority of discharge letters to primary care did not contain necessary information. ConclusionDespite widespread adoption of national guidance, several areas of DKA management are suboptimal, being associated with avoidable biochemical and clinical risk.

show abstract

Section: Hypoglycaemiacontrasting

confidence: 41%

Section: Introductionmentioning

confidence: 99%

National survey of the management of Diabetic Ketoacidosis (DKA) in the UK in 2014

et al. 2015

View full text Add to dashboard Cite

show abstract

“…We doubt this contributed to excessive hypoglycaemia in our fixed‐rate cohort. An initial insulin bolus has not previously been associated with increased hypoglycaemia, and our 24‐h hypoglycaemia incidence of 32.5% was actually lower than the 40% reported in the British study sharing our hypoglycaemia definition . Also, though we provided an identical dextrose infusion rate as in British guidelines, we did so in a 5% solution, whereas British guidelines use a 10% solution at 125 ml/h.…”

Section: Discussionmentioning

confidence: 99%

“…High rates of hypoglycaemia have been reported following implementation of British guidelines. A single centre reported a 40% incidence of hypoglycaemia within 24 h of DKA diagnosis, despite infusion of dextrose in accordance with guideline recommendations . A national survey, in which the threshold for hypoglycaemia was defined by respondents, described a 27.6% incidence .…”

Section: Introductionmentioning

confidence: 99%

Fixed-rate insulin for adult diabetic ketoacidosis is associated with more frequent hypoglycaemia than rate-reduction method: a retrospective cohort study

Lorenson

Cusumano

Stewart

et al. 2019

International Journal of Pharmacy Practice

View full text Add to dashboard Cite

Objective To assess whether hypoglycaemia incidence during management of adult diabetic ketoacidosis (DKA) differed following transition from a fixed‐rate insulin protocol to a protocol using an empiric insulin rate reduction after normoglycaemia. Methods We retrospectively reviewed charts from adult patients managed with a DKA order set before and after order set revision. In cohort 1 (n = 77), insulin rate was 0.1 unit/kg/h with no adjustments and dextrose was infused at 12.5 g/h after glucose reached 250 mg/dl. In cohort 2 (n = 78), insulin was reduced to 0.05 unit/kg/h concurrent with dextrose initiation at 12.5 g/h after glucose reached 200 mg/dl. The primary outcome was hypoglycaemia (glucose < 70 mg/dl) within 24 h of the first order for insulin. Key findings The 24‐h incidence of hypoglycaemia was 19.2% in cohort 2 versus 32.5% in cohort 1; the adjusted odds ratio was 0.46 (95% confidence interval (CI) [0.21, 0.98]; P = 0.047). The 24‐h use of dextrose 50% in water (D50W) was also reduced in cohort 2. No differences were seen in anion gap or bicarbonate normalization, rebound hyperglycaemia or ICU length of stay. In most patients who became hypoglycaemic, the preceding glucose value was below 100 mg/dl. Conclusions The insulin rate‐reduction protocol was associated with less hypoglycaemia and no obvious disadvantage. Robust intervention for low‐normal glucose values could plausibly achieve low hypoglycaemia rates with either approach.

show abstract

“…In a UK national survey of the management of DKA, hypoglycaemia (blood glucose <4 mmol/L) was observed in 28% of patients whereas the incidence of hypokalaemia (serum potassium <4 mmol/L) was as high as 67% . In another study published from a large UK teaching hospital, 40% developed hypoglycaemia within the first 24 hours, and 46% developed hypokalaemia …”

Section: Management Of Dka and Associated Challengesmentioning

confidence: 99%

Successful management of diabetic ketoacidosis: an innovative protocol

Phillips

Sinha

2018

Practical Diabetes

View full text Add to dashboard Cite

As the prevalence of diabetes increases worldwide, so the numbers of hospital admissions with patients suffering complications, such as diabetic ketoacidosis (DKA), have risen. Morbidity and mortality are affected by delays in presentation and diagnosis, and complications of management. In March 2010, the Joint British Diabetes Societies (JBDS) published national UK guidance on the management of DKA, which was updated in 2013. Both national and local surveys performed since have demonstrated high rates of hypoglycaemia and hypokalaemia, potentially life‐threatening complications. The West Suffolk Hospital critical care unit guideline incorporates additional safety features to avoid both hypoglycaemia and hypokalaemia, compared with the JBDS guidelines. Retrospective case note review was performed in May 2015 and May 2017 of patients admitted to the critical care unit in the preceding 18 and 15 months meeting the JBDS diagnostic criteria. Our results showed only 15% and 9% of our patients experienced hypoglycaemia, in contrast with 28% in the national DKA survey. While our incidence of hypokalaemia was similar to the national survey, adjustments to our guideline in December 2015 resulted in a marked decrease in the percentage of time spent hypokalaemic by patients on fixed rate intravenous insulin. We believe there is capacity for improvement of DKA guidelines to reduce the incidence of complications of management, and encourage adjustment of guidelines following our findings. Copyright © 2018 John Wiley & Sons.

show abstract

Management of diabetic ketoacidosis following implementation of the JBDS guidelines: Where are we and where should we go?

Cited by 24 publications

References 11 publications

National survey of the management of Diabetic Ketoacidosis (DKA) in the UK in 2014

National survey of the management of Diabetic Ketoacidosis (DKA) in the UK in 2014

Fixed-rate insulin for adult diabetic ketoacidosis is associated with more frequent hypoglycaemia than rate-reduction method: a retrospective cohort study

Successful management of diabetic ketoacidosis: an innovative protocol

Contact Info

Product

Resources

About