Fluid Management in Diabetic Ketoacidosis
Fluid Management in Diabetic Ketoacidosis
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.
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. 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. 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. Hyperglycaemia is a common feature, but normoglycaemic DKA has been described.
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. 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. 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.
The Joint British Diabetes Societies, supported by NHS Diabetes, published national guidelines on the acute management of DKA in March 2010 (Table 1). These guidelines advise on the management once the diagnosis of DKA has 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. 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.
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. 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. 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. Hyperglycaemia is a common feature, but normoglycaemic DKA has been described.
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. 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. 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.
The Joint British Diabetes Societies, supported by NHS Diabetes, published national guidelines on the acute management of DKA in March 2010 (Table 1). These guidelines advise on the management once the diagnosis of DKA has 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. 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.