Development of a national Scottish diabetic ketoacidosis protocol

Abstract

Diabetic ketoacidosis (DKA) is a common diabetic emergency often managed by general physicians. However, in contrast to its management in children, there was no national guideline/protocol for adults until the recent national protocol was issued for use throughout Scotland. This national protocol was developed from the audit activity described in this article. A prospective audit of the management of DKA and local protocol adherence was carried out at Raigmore Hospital, Inverness (April 2000 to March 2001). This showed deficiencies in the management of DKA with delay in intravenous fluid and insulin administration, and laboratory monitoring being undertaken less frequently than recommended by local guidelines. In addition, 14 DKA management protocols from 17 Scottish trusts were reviewed. The rate and volume of fluid replacement varied slightly between the trusts. There was general agreement within protocols on laboratory monitoring, potassium replacement, insulin administration and bicarbonate usage. The audit showed that there was scope for improvement in the management of DKA and that there were sufficient similarities in protocols used throughout Scotland to allow collaboration on a national protocol. It is anticipated that this will serve to enhance the profile of guidelines and facilitate standardisation and therefore improvement in patient care. Copyright © 2007 John Wiley & Sons.

Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis

“…National and international paediatric guidelines recommend cautious fluid replacement over 48 h. Existing adult guidelines [9,10,12] all recommend rapid initial fluid replacement in the first few hours. No randomized controlled trials exist to guide decision making in this area.…”

“…There are several existing national and international guidelines for the management of diabetic ketoacidosis in both adults and children [8][9][10][11][12]. The Joint British Diabetes Societies guidelines take into account developments in technology and changes in the presentation of diabetic ketoacidosis over the last few years.…”

Impact of diabetic ketoacidosis management in the medical intensive care unit after order set implementation

“…The literature reports inconsistent adherence to published guidelines for the management of DKA. A 2007 prospective review concluded that there was a delay in intravenous fluids and insulin administration at a Scottish hospital, prompting the development of a national protocol . Singh et al .…”

“…The American Diabetes Association (ADA) guidelines, introduced in 2006 and updated in 2009, recommend rapid diagnosis of DKA and aggressive treatment with intravenous fluids and regular insulin (Table ) . Despite this recommendation, studies have demonstrated inconsistent adherence . A previous retrospective evaluation at our institution conducted from 1 July 2007 to 30 June 2010 assessed compliance to the 2006 ADA DKA management guidelines in 60 patients who were admitted to the medical intensive care unit (MICU) with DKA.…”