HNY Policy and Pathway Repository - Humber

Diabetes Ketoacidosis occurs when there is a lack of insulin production and/or insulin resistance, which leads to impairment of carbohydrate, protein, and fat metabolism which created elevated glucose in the blood stream.  Without the metabolisation of the glucose (by insulin) the glucose becomes toxic in the production of ketones which are an acid.

Diabetic ketoacidosis is a medical emergency with a significant morbidity and mortality.  If left untreated it can lead to hyperosmolar hyperglycaemic state (HHA), coma and death.

Many people with diabetes are educated to handle mild DKA and may contact the diabetes team independently to treat at home with the specialists support.  For severe DKA an admission is required.

No Red Flags Listed

Important Referral Checks

Diabetic ketoacidosis (DKA) consists of the biochemical triad of ketonaemia, hyperglycaemia, and acidaemia.

DKA should be diagnosed where there is:

• Ketonaemia greater than 3mmol/L or significant ketonuria (more than 2+ on standard urine stick)
• Blood glucose over 11mmol/L or known diabetes mellitus (DM); and

Standard urine analysis or a blood ketone reading can be used to diagnose DKA with an elevated blood glucose reading.  Clinical assessment for severity should also include:

• Respiratory rate
• Temperature
• Blood pressure (BP) pulse
• Oxygen saturation
• Glasgow Coma Scale (GCS)

Severe DKA may be indicated where one or more of the following are present – in these circumstances consider admission to an environment suitable/equipped for the insertion of a central line, and immediate senior review [for example Diabetes Centre or AAU]:

• Blood ketones more than 6mmol/L
• Bicarbonate level less than 5mmol/L
• Venous/arterial pH less than 7.1
• Hypokalaemia on admission (less than 3.5mmol/L)
• Glasgow Coma Scale (GCS) less than 12 or abnormal AVPU scale
• Oxygen saturation below 92% on air (assuming normal baseline respiratory function)
• Systolic blood pressure (BP) less than 90mmHg
• Pulse over 100 or below 60 beats/minute
• Anion gap above 16 – Anion Gap = (Na+ + K+) – (Cl- + HCO3-)

For those under the age of 18 years of age contact should be made with the paediatric team.

For adults, including those with gestational diabetes contact should be made the Diabetes Specialist team. Please consult Diagnosing diabetes - Ketoacidosis/ Urgent scenario

Both are urgent referrals and the call should be made through the team directly:-

Emergency Paediatric Team

• Paediatric Senior House Officer / Registrar
• Telephone 01482 328541 (Hospital switchboard)

Adults

• Contact HEYHT switchboard (01482) 328541 and ask for the diabetes consultant on call for endocrinology or refer to AAU for imediated commencement of treatment and further blood analysis.

Diagnosing diabetes - Ketoacidosis/ Urgent scenario

Oral Glucose Tolereance Test