Signs and Symptoms
What are some common symptoms of DKA?
Increased Thirst
Weight Loss
Polyuria
Polydipsia
Ketone Breath
Nausea + Vomiting
Precipitating event e.g. Gastroenteritis
Altered Conscious State
Pale + Lethargic
What does DKA stand for?
Diabetic Ketoacidosis
What assessment do you initially conduct for a patient presenting with likely DKA?
Primary Assessment - DRSABCDE
What fluid do we resuscitate with initially regardless of shocked or moderate hypovolemia?
Normal Saline 0.9% 1L over 30 minutes
What are some nursing considerations when caring for a patient on the DKA pathway (acute vs. chronic)
Referrals - Diabetes Educator, Social Work, Dietician, MH involvement, GP
Patient Education - Monitoring device options, medication compliance
Pressure Area Care - IVC's, does the patient need an ART Line or CVC?
Communication with patient regarding plan, ongoing treatment, NBM
Offer comfort measures, pillow, warm blankets, call support person
What abnormal vital signs will you typically see in a DKA presentation?
Tachycardia
Hypotension
Tachypnoea
Febrile (depending on underlying cause)
Altered GCS
Abdominal Pain
What BSL typically indicates DKA? e.g. > ... mmol/L
>11 mmol/L
What resources will you require when treating a patient presenting with DKA?
DKA Master Template (Pathway)
DKA CPG
Insulin CPG
Insulin/Glucose Infusion Form
Intravenous Therapy Chart
AIDH/AMH
What medication and dose do we start post 1st Litre of IVT?
STAT Actrapid IV Bolus 0.1units/kg
What is the treatment if the glucose drops below <15mmol?
Commence Dextrose 10% 12 hourly
What is deep, rapid respirations used to compensate for metabolic acidosis?
Kussmaul Breathing
What Capillary Ketones typically indicate DKA? e.g. >... mmol/L
>0.6 mmol/L
What are your initial nursing interventions for a patient presenting with DKA?
Capillary Ketones, UEC, FBE, FWT + Urine specimen, VBG/ABG, CXR, IVC x2 at least, ideally 3, Cardiac Monitoring
What medication and starting dose is given post bolus of Insulin? How do you make up this infusion?
Actrapid Infusion 0.05 units/kg/hr
50 Units Actrapid in 50ml N/Saline via syringe driver (make sure to prime line with made up infusion dose or separately make up 10 units Actrapid + 10ml N/Saline, flush entire syringe through line)
What bloods need repeating and how often?
Initially 1/24hrly VBG/ABG including Ketones + Vital signs until stable, 2/24hrly UEC + 4/24 VBG Once stable
What is ketone breath? How would you describe this?
Fruity breath odour caused by acetone
What pH and HCO3 levels typically indicate DKA?
pH <7.30
HCO3 <15
What criteria must the patient meet in order to qualify for the Best DKA Study?
No more than 2L Crystalloids
Meet DKA criteria
At what K+ level is it appropriate to commence K+ replacement?
Bonus Prize - can you list the K+/replacement parameters as per the DKA pathway
>3.5 but <5.5
If K+ <3.5 - delay infusion insulin infusion and give 20mmol K+ replacement
What is the patient's likely disposition once commenced on a DKA pathway?
Consider Early ICU review and Endocrinology Consultation, possible ward admit depending on patient.
Refer to DKA pathway for ICU specific criteria for admission
What is the difference between DKA and HHS?
DKA is Diabetic Ketoacidosis and HHS is Hyperosmolar Hyperglycemic State.
Typically, DKA is Type 1 Diabetics and HHS is Type 2 Diabetics (not always the case but most common).
Difference in treatment plans regarding fluid resuscitation.
Interpret this VBG -
pH - 7.0, pCO2 - 22, HCO3 - 10, Na - 123, K - 4.0, Glucose - 40, Lactate - 4.4
Metabolic Acidosis with partial respiratory compensation, hyperglycemia, lactic acidosis
Describe the mechanism of action of Insulin and Potassium in reference to DKA.
Insulin reduces glucose levels by moving glucose from the bloodstream into the cells, dropping hyperglycemia.
Potassium replacement is important in DKA as Insulin drives K+ into the cells, without replacement, K+ levels will continue to drop and remain in the bloodstream.
What drop in glucose levels do we aim for hourly when treating DKA? e.g. ... mmol/L/hr
3 - 4 mmol/L/hr