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Fluid Management in Diabetic Ketoacidosis

Are We Adhering to Recommended Guidelines?
Robert Freudenthal, Nicola Tufton, Christine Podesta, Rebecca Mulholland, Michela Rossi British Journal of Diabetes and Vascular Disease. 2013;13(3):138-142.

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

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 1015 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.

Patients with discharge diagnosis of DKA Excluded after review of case notes (did not meet DKA criteria) Case notes unable to be located Included in audit

2008 2009 2010 2011 53 24 0 29 56 32 0 24 44 14 1 29 47 17 3 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 Received intravenous fluids within 60 minutes Received insulin within 60 minutes Received hourly capillary blood glucose monitoring Mean time to administration of intravenous fluids (min) Median time to administration of intravenous fluids (min) Range of times to administration of intravenous fluids (min)

2008

2009

2010

2011 20 (74.1%) 13 (48.1%) 27 (100%) 56 37 0220 27 (2 sets of notes had

17 11 17 (60.7%) (58.6%) (45.8%) 21 7 13 (46.4%) (72.4%) (29.2%) 22 20 26 (92.9%) (75.9%) (83.3%) 62 46 0236 62 75 55 45

12215 0123 28 (1 set 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 Total number audited 24 29 18 24 22 29 24 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: 27392748. 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: 46671. 3. Centers for Disease Control and Prevention. Diabetes data and trends. http://www.cdc.gov/diabetes/statistics/mortalitydka/fRateDKAGenAgeAdjusted.htm (Accessed June 20, 2013).

4. Clark JD, McConnell A, Hartog M. Normoglycaemic ketoacidosis in a woman with gestational diabetes. Diabet Med 1991; 8: 3889. 5. Bird S. Failure to diagnose: diabetic ketoacidosis. Aust Fam Physician 2010; 39: 8678. 6. Singh RK, Perros P, Frier BM. Hospital management of diabetic ketoacidosis: are clinical guidelines implemented effectively? Diabet Med 1997; 14: 4826. 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: 15802. 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: 2332. 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/Carerecommendations/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: 7739. Acknowledgments We wish to acknowledge all those that assisted in auditing: Jason Cheung, Richard Fish, Kalyan Gurazada, Arif Hamda, 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.