Managing diabetic ketoacidosis

Published: 02 December 2008

KATE SLOWEY, Diabetes Specialist Nurse at South Eastern Trust in Northern Ireland, has recently completed the BSc Hons in Specialist Practice (Diabetes). Here she gives us a summary of an assignment she did on diabetes ketoacidosis.

There are two forms of diabetes emergency caused by hyperglycaemia (that is, higher than normal levels of glucose in the blood): diabetes ketoacidosis (DKA) and hyperosmolar hyperglycaemia state (HHS), which was previously termed hyperosmolar non-ketotic diabetic coma (HONK).

Both can occur in type 1 and type 2 diabetes patients although HHS is more common in type 2. Ketoacidosis and hyperosmolar hyperglycaemia are considered to be the two most serious acute metabolic complications of diabetes, even if they are managed properly (Kitabchi et al, 2004).

There are a number of precipitating factors in DKA:

  • non-compliance (59%)
  • acute illness accounting for 18%
  • new onset of diabetes accounting for 23%
  • psychological problems complicated by eating disorders in young females with type 1 diabetes may account for 20% of recurrent DKA cases.

It is important when treating hyperglycaemia diabetes emergencies that medical staff investigate and identify the precipitating factor, with the hope of educating and preventing recurrence.

Prompt diagnosis to prevent deaths

Chiasson et al. (2003) estimate mortality rates for DKA in Canada at between four and ten per cent of all cases. Hamblin et al. (1989) states the mortality rates for patients with DKA who are treated in an experienced centre is less than five per cent, and DKA accounts for 15 per cent of all deaths in people living with type 1 diabetes, who are generally under the age of 50.

Therefore, it is imperative for health care professionals to prevent morbidity and mortality by prompt assessment and diagnosis, and to implement their locally agreed evidence-based policy for management of hyperglycaemia diabetes emergencies, which may need to be adapted depending on the patient's individual clinical condition.

Wang J et al. (2006) state that although mortality rates have been declining since 1985, there is scope for improvement. They suggest that improved access to specialist centres and education on self management for the person living with diabetes will reduce hyperglycaemic emergencies.

Developing a policy for management

Diabetes ketoacidiosis and hyperglycaemia hyperosmolarity states are serious and life threatening medical emergencies requiring immediate diagnosis and effective management to prevent undesirable outcomes. Although the rate of death and complications in relation to diabetes hyperglycaemic emergencies is decreasing, the development of an effective policy will improve the patient's outcome.

The prevention of hyperglycaemic emergencies is also an important part of the diabetes specialist nurse's role. Therefore, education should be provided regularly and people living with diabetes should have effective access to specialist services.

Currently there is no national policy available for the management of DKA. In 2007 the Diabetes Inpatient National Network (DINN) was formed to review current management of diabetes in the acute setting. Diabetes UK has endorsed this committee to review current inpatient policies including management of DKA with the hope of developing national guidelines within the next two-to-three years.

References on request.