Clinical Practice Guidelines: Management of Type 2 ...jknj.jknj.moh.gov.my/ncd/diabetes/12 -Diabetic...
Transcript of Clinical Practice Guidelines: Management of Type 2 ...jknj.jknj.moh.gov.my/ncd/diabetes/12 -Diabetic...
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Clinical Practice Guidelines: Management of
Type 2 Diabetes Mellitus (5th Edition) 2015
Topic 12
Management of diabetic emergencies:
Diabetes ketoacidosis
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Diabetic Ketoacidosis
• Most serious acute complications.
• High mortality rate if unrecognised. The overall mortality is
<1%, mortality rate >5% in the elderly.
• Precipitating factors: infection, missed therapy, acute
coronary syndrome, CVA, surgery etc.
• Diagnostic criteria: (All three must be met)
• Capillary blood glucose >11 mmol/L
• Capillary ketones >3 mmol/L or urine ketones ≥2+
• Venous pH <7.3 and/or bicarbonate <15 mmol/L
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High Dependency Unit Care
• High-dependency unit (HDU)admission and insertion of
central line in the following circumstances:
• Elderly
• Pregnant ladies
• Heart or kidney failure
• Other serious comorbidities
• Severe DKA
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Criteria For Severe Ketoacidosis
• Venous bicarbonate <5 mmol/L
• Blood ketones >6 mmol/L
• Venous pH <7.1
• Hypokalaemia on admission (<3.5 mmol/L)
• Glasgow Coma Scale (GCS)<12
• Oxygen saturation <92% on air (arterial blood gases
required)
• Systolic BP <90 mmHg
• Pulse >100 or< 60 beats/minute
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Principles Of Management – 1st Hour
Modified from Management of DKA in Adults, NHS Trafford Diabetes, January 2012
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Fluid And Potassium Replacement
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2-6th Hour
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6-12th Hour
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12-24 Hours
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Resolution Of DKA
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What is the next step of management?
Expectation: Patient should be eating and drinking and
back on normal insulin
• If DKA is not resolved identify and treat the reasons for
failure to respond
• Convert to subcutaneous regime when biochemically stable
(blood ketones <0.3 mmol/L, pH >7.3) and the patient is
ready and able to eat.
Do not discontinue intravenous insulin infusion until 30
minutes after subcutaneous short acting insulin has been
given.
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What is the next step of management?
Calculating subcutaneous insulin dose in insulin-naïve
patients; Calculating a Basal Bolus (QID) Regimen.
• Estimate Total Daily Dose (TDD) of Insulin. The TDD can be
calculated by multiplying the patient’s weight (in kg) by 0.5 to
0.75 units.
• Use 0.75 units/kg for those thought to be more insulin
resistant e.g. obese, acanthosis nigricans
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Example
An 80-kg person would require approximately 80 x 0.5
units or 40 units in 24 hours.
Give 50% of total dose at bedtime in the form of long
acting insulin and divide remaining dose equally between
pre-breakfast, pre-lunch and pre-evening meal.
E.g. Short-acting insulin 7u tid & 20 units bedtime