Managing diabetic

ketoacidosis in adults:
New national guidance
from the JBDS
Article points
1. Diabetic ketoacidosis
Mark Savage, Louise Hilton
(DKA) is a metabolic
abnormality associated Diabetic ketoacidosis (DKA) is a life-threatening metabolic
with type 1 diabetes.
abnormality associated with type 1 diabetes. It results from
2. The Joint British Diabetes absolute or relative insulin deficiency, with an associated
Societies (JBDS) have
developed updated
increase in counter-regulatory hormones which increase hepatic
guidelines on the glucose production, inducing severe hyperglycaemia. Despite
management of DKA improvements in diabetes care, it remains a significant clinical
and first recommend
involvement of a diabetes
problem. As a result, the Joint British Diabetes Societies (JBDS)
specialist team. has produced updated guidance for the management of DKA
3. A fixed-rate intravenous
to reflect developments in technology and new practice in the
insulin infusion is UK. A number of new recommendations have been introduced,
recommended with bedside including prompt referral to the diabetes specialist team and the
measurement of blood levels
of ketones and glucose.
use of ketone meters. This article summarises the JBDS guideline
and discusses the implications of standardised treatment in
4. Continuation of long-
acting insulin analogues is
departments admitting people with DKA.
advised to avoid rebound

D
hyperglycaemia. iabetic ketoacidosis (DKA) is the hypokalaemia (low blood potassium
classic metabolic abnormality levels), adult respiratory distress syndrome
Key words
associated with type 1 diabetes. and comorbid states such as pneumonia,
- Diabetic ketoacidosis
Although preventable, DKA is a frequent and acute myocardial infarction and sepsis
- Inpatient care
- Joint British Diabetes life-threatening complication, and is associated (Hamblin et al, 1989).
Societies with significant morbidity and mortality The true incidence of DKA is difficult to
- Ketone (Hamblin et al, 1989). Despite improvements establish, although population-based studies
in diabetes care (Fishbein and Palumbo, 1995; report rates that range from 4.6 to 8 episodes
Umpierrez et al, 1997) it remains a significant per 1000 people with diabetes (Johnson et al,
clinical problem, and although mortality rates 1980; Faich et al, 1983).
have fallen significantly in the past 20 years, To address these issues, the Joint British
from 7.96% in 1982 to 0.67% in 2002 (Lin Diabetes Societies (JBDS), with support
et al, 2005), early diagnosis and effective from NHS Diabetes, has developed
management of the condition is vital. up-to-date guidance for the management of
Author details can be found The main causes of mortality in the DKA in adults. This article explores the key
at the end of this article. adult population with DKA include severe recommendations made by the guideline and

220 Journal of Diabetes Nursing Vol 14 No 6 2010

 Managing diabetic ketoacidosis in adults: New national guidance from the JBDS

discusses the implications both for people with Osmotic diuresis due to hyperglycaemia, Page points
DKA and for nurses charged with their care. as well as other factors, can lead to serious 1. In the past decade there
problems such as fluid depravation, and is has been a change in the
Purpose of the guideline also related to electrolyte shifts and depletion, way that people with
The guideline, The Management of Diabetic resulting in hyper- and hypokalaemia. diabetic ketoacidosis
(DKA) present clinically,
Ketoacidosis in Adults (Savage et al, 2010),
Diagnosis with partially treated DKA
is intended for use by clinicians and service and consequently lower
commissioners in delivering high-quality care for Absolute diagnostic criteria for DKA blood glucose levels.
people admitted to hospital with DKA. do not exist, however the following are
2. DKA occurs as a result of
There are several currently available proposed in the guideline (Savage et al, absolute or relative insulin
national and international guidelines for 2010): ketonaemia >3 mmol/L or significant deficiency accompanied by
the management of DKA both in adults ketonuria (more than 2+ on standard urine an increase in counter-
and children (Savage et al, 2006; McGeoch sticks); blood glucose >11 mmol/L or known regulatory hormones.
et al, 2007; British Society for Paediatric diabetes; and venous bicarbonate (HCO3) 3. Osmotic diuresis due to
Endocrinology and Diabetes [BSPED], <15 mmol/L and/or venous pH <7.3. It is hyperglycaemia, as well as
2009; International Society for Pediatric not necessary to measure arterial pH as this other factors, can lead to
serious problems such as
and Adolescent Diabetes [ISPAD], 2009; is not significantly different from venous pH
fluid depravation, and is
Kitabchi et al, 2009). (Kelly, 2006). Table 1 outlines the signs and also related to electrolyte
In the past decade, however, there has symptoms of DKA. shifts and depletion,
been a change in the way that people with resulting in hyper- and
DKA present clinically, with partially Developments in management hypokalaemia.
treated DKA and consequently lower blood Diabetes teams have been using ketone
glucose levels. In addition, there has been meters with increasing regularity to manage
rapid development of near-patient testing outpatients with type 1 diabetes. Until
technology, which is now readily available for recently, the management of DKA has
monitoring blood ketone levels, allowing for focused on addressing hyperglycaemia with
a shift away from the dependence on blood fluids and insulin, and using arterial pH
glucose levels to drive treatment decisions in and serum bicarbonate to assess metabolic
the management of DKA.
The guideline discussed in this article Table 1. Signs and symptoms of diabetic ketoacidosis.
(Savage et al, 2010) updates the currently
available UK-based guidelines, and has been Signs l Deep, rapid breathing.
endorsed by the JBDS. It has been developed l Dry skin and mouth.
to reflect the advances in technology and l Flushed face.
new practice in the UK. They are evidence l Fruity breath (fruit drop odour).
based, where possible, but are also drawn l Nausea and vomiting.
from pooled multiprofessional knowledge and
l Stomach pain.
consensus agreement.
Symptoms l Fatigue.
Pathophysiology l Frequent urination or thirst for 1 day or more.
DKA occurs as a result of absolute or relative l Mental stupor that may progress to coma.
insulin deficiency accompanied by an increase
l Muscle stiffness or aching.
in counter-regulatory hormones. This
l Shortness of breath.
hormonal imbalance increases hepatic glucose
production, resulting in severe hyperglycaemia. l Abdominal pain.
Enhanced fat breakdown increases serum- l Decreased appetite.
free fatty acids, which are then metabolised, l Decreased consciousness.
producing large quantities of ketone bodies l Headache.
and consequently results in metabolic acidosis.

Journal of Diabetes Nursing Vol 14 No 6 2010 221

Managing diabetic ketoacidosis in adults: New national guidance from the JBDS

Page points improvement based on the assumption that involvement, shorten inpatient stay and
1. The guideline this would suppress ketogenesis and reverse improve safety (Levitan et al, 1995; Cavan
recommends that the the process of acidosis. at al, 2001; Davies at al, 2001). The present
management of people It is now possible, however, to focus on guideline recommends that diabetes specialist
with diabetic ketoacidosis the underlying metabolic abnormality − team involvement should occur “as soon as
is based on bedside
ketonaemia − which simplifies treatment possible” during the acute phase, pointing
monitoring.
of people who present with modest out that the practice of admitting, treating
2. All people admitted hyperglycaemia but with acidosis secondary and discharging people admitted to hospital
to hospital should be
to ketonaemia, a condition known as with DKA without the involvement of the
reviewed by a member
of the diabetes specialist “euglycaemic diabetic ketoacidosis” diabetes specialist teams is unsafe and likely
team prior to discharge (Munro et al, 1973; Johnson et al, 1980; to compromise safe patient care.
to maintain safety and Jenkins et al, 1993). This clinical presentation DISNs are pivotal in reviewing people
optimise care. is being encountered more frequently. with DKA, establishing the cause and
3. The main aims of fluid The guideline recommends that the educating the individuals around treatment
replacement are to restore management of people with DKA is based and sick-day rules. All people admitted to
circulatory volume, clear on bedside monitoring. Blood glucose is hospital should be reviewed by a member
ketones and correct
routinely checked at the bedside, but portable of the diabetes specialist team prior to
electrolyte imbalance.
ketone meters now also allow bedside discharge to maintain safety and optimise
4. In people with kidney measurement of 3-beta-hydroxybutyrate, care (Clement et al, 2004). Box 1 gives
or heart failure, as well
which is an important advance in DKA a case study highlighting some common
as older people and
adolescents, there may management (Vanelli et al, 2003; Bektas issues related to the management of people
be a need to modify the et al, 2004; Khan et al, 2004; Wallace and admitted with DKA.
rate and volume of fluid Matthews, 2004; Naunheim et al, 2006;
replacement. Sheikh-Ali et al, 2008). The treatment General management issues
of DKA depends on the suppression of There is common agreement that the most
ketonaemia, therefore measurement of blood important initial therapeutic intervention
ketones now represents best practice in in people with DKA is appropriate fluid
monitoring the response to DKA treatment replacement followed by insulin administration
(Wiggam et al, 1997). (Savage et al, 2006; Kitabchi et al, 2009). The
The majority of blood-gas analysers main aims of fluid replacement are to restore
currently available provide measurements circulatory volume, clear ketones and correct
of blood gas and electrolytes at the bedside electrolyte imbalance. For example, an adult
within a few minutes of blood being taken. weighing 70 kg presenting with DKA may be
The guideline therefore recommends that up to 7 litres in fluid deficit, with associated
glucose, ketones and electrolytes, including electrolyte deficits.
bicarbonate and venous pH, should be In people with kidney or heart failure, as
assessed at or near the bedside. well as older people and adolescents, there
The guideline recognises that not all may be a need to modify the rate and volume
units have access to ketone meters, therefore of fluid replacement. The aim of the first few
recommendations are also given on litres of fluid is to correct any hypotension,
monitoring treatment using the rate of rise address the intravascular deficit and offset the
of bicarbonate and fall in blood glucose as effects of the osmotic diuresis with correction
alternative measures. of electrolyte disturbance.

Involvement of diabetes Assessment of severity

specialist teams The presence of one or more of the following
Evidence has consistently shown that may indicate severe DKA:
diabetes specialist teams, particularly with l Blood ketones over 6 mmol/L.
diabetes inpatient specialist nurse (DISN) l Bicarbonate level below 5 mmol/L.

222 Journal of Diabetes Nursing Vol 14 No 6 2010

 Managing diabetic ketoacidosis in adults: New national guidance from the JBDS

l Blood pH below 7.1. glucose levels fall below 14 mmol/L. It is

l Hypokalaemia on admission (less than important to continue 0.9% sodium chloride
3.5 mmol/L). solution concurrently via an intravenous pump.
l Glasgow Coma Scale less than 12 or Glucose should not be discontinued until
obtunded patient. the person is eating and drinking normally
l Oxygen saturation less than 92% on air (Savage et al, 2010).
(assuming normal baseline respiratory
function). Continuation of long-acting
l Systolic blood pressure below 90 mmHg. analogue insulin
l Pulse over 100 or below 60 beats per For the initial management of DKA,
minute. continuation of long-acting analogue insulin is
Admission to a level 2 high-dependency unit recommended to provide background insulin
environment, insertion of a central line and when the intravenous insulin is discontinued.
immediate senior review should be considered. This avoids rebound hyperglycaemia when

Insulin therapy and metabolic Box 1. Case study.

treatment targets
The guideline recommends a fixed-rate Narrative
intravenous insulin infusion (FRIVII) A 19-year-old woman was admitted to hospital at 17:00 hours with
calculated on 0.1 units/kg. As global obesity a 2-day history of flu-like symptoms. She had been diagnosed with
continues to escalate, people with DKA are type 1 diabetes 3 months earlier. As she was unable to eat her normal
now more likely to be overweight or obese, or food she had felt it best to stop taking her fast-acting pre-meal
presenting with other insulin-resistant states insulin, although she had continued her long-acting bedtime analogue
such as pregnancy. This has led to the re- insulin. She was polyuric and polydipsic and her breath smelt of nail
emergence of FRIVII in adults in the USA and varnish remover (ketones).
international paediatric practice (BSPED, 2009; The on-call medical staff checked her oxygen saturations on air
ISPAD, 2009; Kitabchi et al, 2009). (99%) and proceeded to take blood samples. Venous pH and bicarbonate
Fixed dose(s) per kilogram of body weight levels measured on the ward blood-gas analyser confirmed acidosis
enable rapid blood ketone clearance, but with a pH of 7.1 and a bicarbonate of 6 mmol/L. Serum potassium
it requires close monitoring and may need was 4.9 mmol/L. Finger-prick testing for ketones and glucose showed
to be adjusted if the target (shown below) 4.7 and 34.3 mmol/L, respectively.
is not met. The recommended target is a
reduction of the blood ketone concentration by Discussion
0.5 mmol/L/hour; however, if a ketone meter is Her weight was 9 stones (9×14=126 lb divided by 2.2=57 kg); a fixed-
not available the venous bicarbonate should rise rate intravenous insulin infusion at 0.6 units/hr of fast-acting intravenous
by 3 mmol/L/hour and capillary blood glucose insulin was set up along with 1 litre of 0.9% sodium chloride solution with
fall by 3 mmol/L/hour. Potassium should be no potassium in the first bag.
maintained between 4.0 and 5.0 mmol/L. Over the next 6 hours her blood ketone level returned to 0 mmol/L but
her blood glucose fell to below 14 mmol/L and 10% glucose infusion had
Intravenous glucose concentration to be infused alongside the 0.9% sodium chloride infusion.
It is recommended that the management of She felt symptomatically better the next day and was able to eat breakfast
DKA should be focused on clearing ketones as with her normal fast-acting insulin injected after she had eaten, and the
well as normalising glycaemia. Administration intravenous glucose and 0.9% sodium chloride solutions were stopped
of an intravenous infusion of 10% glucose via afterwards. The emergency unit had contacted the diabetes inpatient
an intravenous pump is often required to avoid specialist nurse and, after some further advice on sick-day rules, she was
hypoglycaemia and permit the continuation of provided with a home ketone-measuring device, referred for a 5-day
a FRIVII to suppress ketogenesis.
education package and given contact details for the community diabetes
The guideline recommends the
nursing service. She was in hospital for fewer than 24 hours.
administration of 10% glucose when blood

Journal of Diabetes Nursing Vol 14 No 6 2010 223

Managing diabetic ketoacidosis in adults: New national guidance from the JBDS

Page points intravenous insulin is discontinued, which and trusts must ensure that local protocols
1. Hypokalaemia and should result in a reduced length of hospital that allow for the safe administration of
hyperkalaemia are the stay. This only applies to long-acting analogue concentrated potassium injectable (this may
two most serious acute insulins, however, and short-acting insulin require transfer to a higher care environment).
metabolic complications must still be administered before discontinuing The majority of modern blood analysers
that can arise during the
the intravenous insulin infusion. measure electrolyte levels, and should be used
management of diabetic
ketoacidosis (DKA). to monitor sodium, potassium and bicarbonate
Serious complications of levels at the bedside.
2. The guideline DKA and its treatment
recommends that if the Hypoglycaemia
serum potassium level Hypokalaemia and hyperkalaemia are the two
remains above 5.5 mmol/L, most serious acute metabolic complications As ketoacidosis is treated, blood glucose
no additional potassium that can arise during the management of levels can drop very quickly. A common
should be prescribed. DKA. There is a risk of acute renal failure mistake is to allow the blood glucose to drop
3. As ketoacidosis is treated, as a result of severe dehydration, and it is to hypoglycaemic levels, which can result in
blood glucose levels can therefore recommended that no potassium is rebound ketosis driven by counter-regulatory
drop very quickly. A administered during initial fluid resuscitation. hormones. Severe hypoglycaemia (defined
common mistake is to
Furthermore, the guideline recommends that as requiring third-party assistance) is also
allow the blood glucose
to drop to hypoglycaemic if the serum potassium level remains above associated with cardiac arrhythmias, acute
levels, which can result 5.5 mmol/L, no additional potassium should be brain injury and death. It is partly for this
in rebound ketosis driven prescribed. However, since potassium levels will reason that 10% glucose is recommended.
by counter-regulatory almost always drop as insulin is administered for
hormones. Implications of guidelines for nurses
the treatment of DKA, it is recommended that
0.9% sodium chloride solution with potassium DISNs will be involved in education and,
40 mmol/L (ready mixed) is prescribed, as increasingly, with hands-on treatment of
long as the serum potassium level is below people being admitted with DKA. However,
5.5 mmol/L and the person is passing urine unless there is a diabetes specialist team
(Savage et al, 2010). on-call rota covering 24 hours it is more likely
The guideline states that review of the that nurses working in emergency admission
potassium regimen is required if the serum units and other acute or semi-acute settings
potassium level falls below 3.5 mmol/L. It will be treating people with the condition.
is essential that all aspects of potassium use Thus, nurses will need to be familiar with
comply with local and national guidance hand-held ketone meters. Modern meters for
(National Patient Safety Agency, 2002), ward use also have bar-coding technology
to permit the downloading of data to the
Further information. hospital laboratory and so full training will
need to be implemented.
l Full guidance, including a 1-page pdf summary chart, is available at:
http://tinyurl.com/octswq. For young people under the age of 18 years, Conclusion
contact your paediatric diabetes service and use the British Society DKA is a medical emergency associated
for Paediatric Endocrinology and Diabetes diabetic ketoacidosis with significant morbidity and mortality. It
guidelines, which can be found at: http://tinyurl.com/32w8dph. should be diagnosed promptly and managed
l Joint British Diabetes Societies consists of: Association of British intensively.
Clinical Diabetologists; British Society for Paediatric Endocrinology The JBDS, in association with NHS Diabetes,
and Diabetes and Association of Children’s Diabetes Clinicians; has produced new guidance for the management
Diabetes Inpatient Specialist Nurse UK Group; Diabetes UK; of this condition. The guideline recommends
NHS Diabetes (England); Northern Irish Diabetologists; Scottish that FRIVII be used with bedside measurement
Diabetes Group; Society of Acute Medicine; Welsh Endocrine and of metabolic parameters; the diabetes specialist
Diabetes Society. team should always be involved as soon as
possible and ideally within 24 hours as this has

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 Managing diabetic ketoacidosis in adults: New national guidance from the JBDS

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