NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

National Clinical Guideline Centre (UK). Type 1 Diabetes in Adults: Diagnosis and Management. London: National Institute for Health and Care Excellence (UK); 2015 Aug. (NICE Guideline, No. 17.)

Cover of Type 1 Diabetes in Adults: Diagnosis and Management

Type 1 Diabetes in Adults: Diagnosis and Management.

Show details

12Ketone monitoring and management of diabetic ketoacidosis (DKA)

The 2015 GDG updated self-monitoring and in hospital monitoring of ketones. The 2004 content that has been superseded by the 2015 update can be found in Appendix S. Management of DKA was not in the scope for the 2015 update and therefore the original recommendations and content from CG15are reproduced in this chapter.

12.1. Ketone monitoring [2015]

12.1.1. Introduction

Ketosis and ketonuria reflect a greater degree of insulin deficiency than hyperglycaemia alone. The presence of ketones indicates that insulin concentrations are too low not only to control blood glucose concentrations but also to prevent the breakdown of fat (lipolysis). Because ketones are acid substances, high ketone concentrations in the blood may create acidosis. Diabetic ketoacidosis (DKA) is a medical emergency and in its established state carries a 0.7–5% mortality in adults.459,476,784

High ketones in the blood are associated with high levels of fatty acids and together create insulin resistance. The patient with significant ketonaemia will require more insulin than usual to control the blood glucose.

Traditionally, ketonaemia has been assessed by urine testing. This has been applied in three main settings: it is recommended as part of guidance for patient self-management of acute illness at home, when patients are advised to increase their usual corrective insulin doses in the presence of significant ketonuria; in the assessment of patients presenting to emergency services with hyperglycaemia, where presence of ketonuria may influence management decisions, including need for admission and in the management of established DKA, where resolution of ketonuria is an important indication of recovery. However, not all ketone bodies are detected by urine testing. For example, beta-hydroxybutyrate (β-OHB) is not detected with current strip tests and if there is a high β-OHB:acetoacetate ratio, urine testing may give a falsely low estimate of ketosis. Furthermore, after an episode of ketoacidosis, where measurement of blood ketones may provide a more accurate assessment of re-insulinisation than blood glucose measurements alone, urine tests, measuring lipid soluble acetone, may continue positive for 48 hours as acetone leaks from fat tissue although ketogenesis and lipolysis have stopped.

Recent advances in technology have included the development of faster, more accurate blood tests for ketones, including strip and meter tests for measuring ketonaemia as β-OHB from a finger prick blood sample. There is a need to assess the evidence base for the use of blood ketone measurement, both laboratory- and strip-based, in three settings:

  • Use of self-assessment of blood ketones as part of home monitoring when hyperglycaemia is detected and the patient is feeling unwell to see if it can improve a patient's ability to manage intercurrent illness at home, reduce hospital admissions and/or reduce the severity of ketoacidosis when someone presents to the emergency services.
  • Use of blood rather than urine ketone measurement in the assessment of patients presenting to emergency services with hyperglycaemia.
  • Use of blood rather than urine ketone measurement in the inpatient management of established ketoacidosis to reduce morbidity and length of stay in either high dependency care and/or the hospital.

The new review questions included in this chapter are:

  • In adults with type 1 diabetes (including atypical ketosis-prone diabetes), does patient self-monitoring of blood (and urine) ketones reduce the incidence of DKA and hospital admissions?
  • In adults with type 1 diabetes, does inpatient monitoring of blood ketones by the healthcare professional reduce the length of hospital stay, exposure to IV insulin and the development of in-hospital complications:
    • in patients with suspected DKA?
    • in patients admitted with DKA and/or those that get it in hospital?

The evidence and text from the previous guideline, CG15, that has been superseded by this update is in Appendix S.

12.1.2. Review question: In adults with type 1 diabetes (including atypical ketosis-prone diabetes), does patient self-monitoring of blood (and urine) ketones reduce the incidence of DKA and hospital admissions?

Table 144. PICO characteristics of review question - self-monitoring.

Table 144

PICO characteristics of review question - self-monitoring.

12.1.3. Review question: In adults with type 1 diabetes, does inpatient monitoring of blood ketones by the healthcare professional reduce the length of hospital stay, exposure to IV insulin and the development of in-hospital complications

  • in patients with suspected DKA?
  • in patients admitted with DKA and/or those that get it in hospital?
Table 145. PICO characteristics of review question - inpatient monitoring.

Table 145

PICO characteristics of review question - inpatient monitoring.

12.2. Clinical evidence

We searched for studies published since the original type 1 diabetes guideline (2003 onwards).

Five studies were included in the review 47,66,298,430,710 One of the studies was a randomised controlled trial (RCT)430. All other studies were non-comparative observational studies, and therefore were not able to be combined in a meta-analysis or GRADE profile, and were graded as Low quality (due to their study design). However, a summary of the quality and limitations of these studies can be found in Appendix G. Evidence from these studies has therefore been summarised narratively, with an overview in Appendix I. See also the study selection flow chart in Appendix D, and study evidence tables in Appendix G and exclusion list in Appendix K.

One study, the RCT 430, looked at ketone self-monitoring. All other studies involved inpatient ketone measurement (point of care testing in the emergency department).

There were no data reported in any of the studies for the following outcomes:

  • length of hospital stay
  • in-hospital complications of the admission
  • quality of life
  • hypoglycaemia

The terms β-OHB and β-HBA have been used throughout the review, according to the terminology reported in the studies. These are alternative acronyms representing the same ketone, beta-hydroxybutyric acid.

Table 146. Summary of studies included in the review (self-monitoring).

Table 146

Summary of studies included in the review (self-monitoring).

Table 147. Summary of studies included in the review (inpatient monitoring).

Table 147

Summary of studies included in the review (inpatient monitoring).

Table 148. Clinical evidence summary: Blood β-HBA versus urine β-HBA ketone measurement (less than or equal to 6 months).

Table 148

Clinical evidence summary: Blood β-HBA versus urine β-HBA ketone measurement (less than or equal to 6 months).

12.3. Economic evidence

Published literature

No relevant economic evaluations comparing either self-monitoring of blood ketones with urine ketones, or hospital-monitoring of blood ketones with urine ketones were identified.

Unit costs

In the absence of recent UK cost-effectiveness analysis, relevant unit costs are provided below to aid consideration of cost-effectiveness.

Table 149. Unit costs for self-monitoring of ketones.

Table 149

Unit costs for self-monitoring of ketones.

Table 150. Unit costs for in-hospital ketone monitoring.

Table 150

Unit costs for in-hospital ketone monitoring.

Table 151. Pooled average cost of non-elective inpatient care for management of DKA.

Table 151

Pooled average cost of non-elective inpatient care for management of DKA.

Table 152. Pooled average cost of non-elective excess bed care days for management of DKA.

Table 152

Pooled average cost of non-elective excess bed care days for management of DKA.

12.3.1. Evidence statements

Clinical

Self-monitoring of β-HBA ketones: blood capillary versus urine

Very low quality evidence from one RCT (n=123) showed:

  • clinical benefit of blood monitoring in reducing both ER use and hospitalisations
  • no clinical benefit of blood monitoring for HbA1c
  • patients preferred blood measurements and found them easier to perform

In the case of ER use and hospitalisations the direction of the estimate of effect favoured blood measurement, with no impact on HbA1c.

Inpatient monitoring

Low quality evidence from four observational studies (n=50 to n=529) showed that point-of-care testing of blood (capillary) β-OHB or β-HBA (in people admitted to the emergency department) was better than urine β-OHB or β-HBA in terms of:

  • sensitivity and specificity of detecting DK and detecting DKA.
  • patients requiring IV insulin treatment.
  • predicting ketoacidosis and hospitalisation

Economic

No relevant economic evaluations were identified.

12.3.2. Recommendations and link to evidence

Recommendations
100.

Consider ketone monitoring (blood or urine) as part of ‘sick-day rules’ for adults with type 1 diabetes, to facilitate self-management of an episode of hyperglycaemia. [new 2015]

101.

In adults with type 1 diabetes presenting to emergency services, consider capillary blood ketone testing if:

  • DKA is suspected or
  • the person has uncontrolled diabetes with a period of illness, and urine ketone testing is positive. [new 2015]
102.

Consider capillary blood ketone testing for inpatient management of DKA in adults with type 1 diabetes that is incorporated into a formal protocol. [new 2015]

Relative values of different outcomesTo determine whether ketone monitoring might be beneficial to individuals with type 1 diabetes, the GDG reviewed the evidence for the use of capillary blood ketone measurement in adults with type 1 diabetes in three clinical settings:
Patient self-assessment of capillary blood ketones as part of home-monitoring during acute illness, when hyperglycaemia is detected and the patient is feeling unwell. Ketone monitoring here might improve the patient's ability to manage intercurrent illness at home, with the possibility of reducing hospital admissions.It could also ensure that patients present to emergency services at the appropriate time, reducing the severity of ketoacidosis at presentation to emergency services

Comparison of capillary blood ketone measurement versus urine ketone measurement undertaken by healthcare staff at the time of patient presentation to the emergency services with hyperglycemia, to determine whether one might be superior in determining the need for patient admission to hospital.

Comparison of blood ketone measurement versus urine ketone measurement in the inpatient management of established ketoacidosis, with the aim of determining which might lead to morbidity reduction and decreased length of stay in hospital in patients with established DKA.

Based on assessment from these three clinical settings, the following outcomes for the use of ketone monitoring were assessed:
Mortality and morbidity – High ketone levels in the blood result in acidosis, and DKA is a medical emergency that in its established state carries a 0.7 to 5 % mortality459,476,785. Ketone testing should allow earlier diagnosis and management of ketosis in individuals with type 1 diabetes and therefore, prevention of complications from DKA.
Emergency admission rates to hospital – Early identification of ketosis in individuals with type 1 diabetes might allow corrective measures to be taken and subsequent treatment at home, potentially avoiding the need for presentation as a medical emergency to healthcare services. Access to ketone testing may allow more effective self-management of intermittent illness associated with hyperglycaemia and subsequent morbidity may be reduced, especially if timely referral to emergency services is enabled.
Assessment of ketonaemia in hospital – Ketonaemia assessment might influence clinical decision making, enabling earlier diagnosis and management of established DKA. Ketone testing might guide insulin dosing in the management of ketoacidosis, and could conceivably reduce admission times for DKA.
Sensitivity and specificity of capillary blood strips versus urine testing for ketones assessment - Ketone testing has traditionally been assessed by urine testing, although, not all ketone bodies are detected by this method of testing. β-OHB is not detected with current urine test strips, and there is the possibility that urine testing can give a falsely low estimate of ketosis.
Recent advances in technology have included the development of capillary blood testing strips for ketonaemia, which measure β-OHB from a finger prick blood sample – The evidence was reviewed to assess their sensitivity and specificity in comparison with urine ketone sticks.
Ease of capillary blood testing versus urine testing for ketones assessment.
Ease of test use is likely to determine frequency of use by both patients and healthcare staff; patients are more likely to be compliant with testing, and healthcare professionals are more likely to adopt the test in management-driven protocols if it is easy to use.
Trade-off between clinical benefits and harmsMortality and morbidity
The GDG looked for published outcomes on whether monitoring for ketones had any impact on electrolyte imbalances, cerebral oedema and mortality during the management of ketoacidosis, but no studies were available for review following evidence searches.

Emergency admission rates to hospital
A single study from the USA showed that the use of blood rather than urine ketone monitoring during home management of intercurrent illness was associated with a reduced attendance rate to the Emergency Room. Although this difference did not achieve statistical significance, the GDG considered this to be of substantial clinical benefit and an important clinical outcome favouring the use of blood ketone monitoring in this setting.430

Assessment of ketonaemia in hospital
Four studies46,66,298,710 showed that capillary blood ketone testing might have advantages over urine ketone testing, and that they could be used as a rapid bedside test to measure accurately blood concentrations of ketones in an emergency department setting. The studies suggested that this might be useful for making early management decisions in patients presenting to emergency departments with suspected DKA.
One study610 showed that length of hospital stay for the management of DKA was reduced from 3.0+/-1.4 days to 1.8+/-0.7 days by the introduction of capillary blood ketone monitoring to an inpatient DKA management protocol. The GDG observed that this protocol followed the Joint British Diabetes Associations (JBDS) DKA management protocol650, and were wary of what influence the combined aspects of the protocol, as opposed to ketone measurement alone, might have had on influencing duration of admission in this study. However, the GDG also recognised that one of the main monitoring tests used in the JBDS protocol was the use of blood ketone monitoring to dictate management decisions, and therefore, it was likely that blood ketone monitoring did influence the duration of hospital admission in this study.

Sensitivity and specificity of capillary blood strips versus urine testing for ketones assessment
Capillary blood ketone assessment was found to be more sensitive than urine testing in two studies46,66, and more specific in three studies46,66,298, while a further study concluded that blood ketones were able to better predict ketoacidosis, hospitalisation and hospitalisation for ketoacidosis management than urine ketones assessment710.

Ease of capillary blood testing versus urine testing for ketones assessment Patients in one study expressed a preference for ketone monitoring over urine ketone monitoring430. As a patient testing for ketones is likely to be already testing their blood for glucose levels, no additional finger pricking is required. The GDG recognised that more frequent measurements of blood ketones were relatively easy to undertake in comparison to urine ketone monitoring.
Economic considerationsNo relevant economic evaluations comparing either self-monitoring or hospital-monitoring of blood ketones with urine ketones were identified.
In the absence of UK cost-effectiveness analysis, the GDG considered the relevant unit costs of blood and urine monitoring to reach its own conclusion regarding cost-effectiveness.

Home monitoring
Blood ketone test strips have a higher initial cost (£20.32 for a pack of 10) than urine ketone test sticks (£2.50 for a pack of 50). However, blood ketone test strips have a longer shelf-life (12-18 months) compared with urine test sticks (3 months). As individuals with type 1 diabetes are likely to test for ketones on an infrequent basis, it is possible that only a fraction of the ketone testing strips or sticks might be used from a provided container before they have passed their expiry date. This wastage will be greater for urine sticks, which partially offsets the lower unit cost. The GDG considered that companies making test strips should provide a lower number of strips or sticks per container to reduce the risk of wastage.
The clinical review showed that blood strip ketone testing rather than urine ketone monitoring during home management of intercurrent illness was associated with a reduced attendance rate to the Emergency Room in individuals with type 1 diabetes. This was considered clinically significant by the GDG and they recognised that allowing adults with type 1 diabetes access to home blood strip ketone monitoring could have substantial cost-saving implications if it resulted in a reduction in hospital admission rates for the management of DKA.
The GDG acknowledged that there may be additional cost implications in that individuals would need education from healthcare staff on how to test for blood ketones and how to interpret the result.

Presentation to emergency services and hospital monitoring
Given the cost of individual blood ketone test strips, the GDG was keen that capillary blood testing did not replace the use of urine testing when screening for ketones. This was with the aim of preventing capillary blood ketone testing becoming ubiquitous amongst healthcare professionals even when suspicion of ketosis is low.
The biochemistry blood test for ketones assessment costs £1.26 per unit, which is cheaper than capillary blood strip ketone testing. However, the GDG recognised that in clinical practice the laboratory-measured result would be available less readily than capillary blood ketone results when making management decisions for insulin infusion rates in the management of DKA.
For the use of capillary blood ketones for inpatient management of DKA, the GDG were presented with the cost of the average length of hospital stay of 3.4 days for the management of DKA (Hospital Episode Statistics 2011-12). The GDG found that provided discharge was safe and would not lead to a recurrence of DKA, capillary blood ketone monitoring would have to reduce length of stay in hospital by more than 0.074 days (or 100 minutes) in order to be cost-saving in comparison to urine ketone monitoring. The GDG observed that one study in the clinical review had shown that switching to a protocol using capillary blood ketone testing in place of urine ketone testing as per the JBDS protocol had reduced length of hospital stay by 1.2 days, and therefore, capillary blood ketone monitoring was likely to be cost-effective for use in the inpatient management of DKA. However, in making its recommendation, the GDG wanted to state explicitly that blood ketone monitoring should only be used as part of an approved protocol for the management of DKA, rather than being used in isolation.
Quality of evidenceSix studies were identified for the review.
Only one of the studies was a RCT, and this assessed self-monitoring of ketones at home and its impact on emergency admission rates430. The population participating in this study was young (age ≤22 years - a mixture of children, young people and young adults) and therefore, caution was taken in interpreting the results from this study and applying the results to the adult population with type 1 diabetes.
The GRADE quality of the study was ‘Very low’, and the GDG expressed concerns about the effect of the study protocol impacting on the final result. Individuals in the trial underwent training on blood ketone monitoring, and had 24 hour access to advice from a physician, and therefore, may have been better able to manage intercurrent illness for reasons other than just ability to monitor ketonaemia. The study also specifically excluded individuals with a previous history of high admission rates for DKA, who would arguably be the target group for assessing the effectiveness of home ketone monitoring.
The other studies for the evidence review were non-comparative observational studies, and therefore, could not be assessed by meta-analysis or GRADE assessment. All five studies assessed the impact of ketone monitoring on inpatient management46,66,298,610,710. These studies were given a ‘Low quality’ rating by the GDG, and therefore, conclusions were drawn with caution when interpreting the data.
Other considerationsMembers of the GDG recognised that the most recent national guidance for DKA management (JBDS guidelines) advised the use of capillary blood ketone testing to facilitate management decisions, and that this guidance was being used in hospitals across the country.
The GDG recognised that the quality of the available evidence regarding capillary blood ketone testing was low, and that there were no RCT data to support the use of capillary blood ketone strips in the emergency department setting. The GDG therefore made a recommendation that research into whether the use of blood ketone strips improves clinical outcome should be undertaken.
Patient members on the GDG expressed a preference for access to capillary blood ketone monitoring over urine ketone monitoring, as it provided a means of testing for ketones that was of greater convenience and the evidence suggested that it provided a more accurate result.

12.3.3. Research recommendations

27.

In adults with type 1 diabetes, what is the clinical and cost effectiveness (particularly in terms of morbidity, reduction in admission rates, and length of stay) of using blood capillary ketone strips compared to urine ketone strips for the management of DKA?

28.

In adults with type 1 diabetes, what is the clinical and cost effectiveness (particularly in terms of morbidity, reduction in admission rates, and length of stay) of using blood capillary ketone strips compared to urine ketone strips for the prevention of DKA?

29.

In adults with type 1 diabetes, what is the clinical and cost effectiveness (particularly in terms of pre-empting admissions) of self-monitoring blood ketones compared to urine ketones?

12.4. Management of DKA [2004]

The management of DKA is a topic which has attracted considerable attention over 40 years because it can carry a high fatality risk if suboptimally managed. If optimally managed, the fatality and morbidity rates are very low. The topic is not easily addressed within a general diabetes guideline, being large enough for a guideline of its own. The approach below is to address some broad principles and specific topics of contention, rather than present a detailed protocol.

12.4.1. Evidence statements [2004]

Insulin therapy

Continuous versus intermittent insulin therapy for DKA was evaluated in one small randomised study.586 Insulin was administered as bolus injections (50 U per 2 hours) compared with continuous insulin infusion (10 U per hour) and low-dose continuous insulin infusion (2 U per hour) with an initial loading dose. To reduce plasma glucose concentrations, continuous infusion is as effective as intermittent insulin therapy at 10 U per hour, with reduction to 5 U per hour when plasma glucose is less than 300 mg/100 ml. DKA recovery rate was significantly reduced following the very low dose continuous infusion regimen (Ib).

Another small study showed that low doses of insulin given by intermittent intramuscular (IM) injection or by constant intravenous (IV) infusion after an initial IV loading dose are similarly effective in controlling DKA.640 Time to recovery of DKA and total insulin dose required did not differ between the two treatment groups (Ib).

A comparison of different possible routes of insulin delivery in treating DKA showed similar efficacy for IV, IM and subcutaneous administered insulin therapy.230 No significant differences were seen for the time to metabolic recovery or total insulin dose or fluid replacement requirements. Patients receiving IM insulin were most likely to require an additional insulin loading dose to achieve an adequate initial response. In this report, a significantly higher rate of decrease in glucose and ketone bodies was observed in the first 2 hours following IV insulin, but these differences were not maintained over the rest of the recovery period (Ib).

No significant differences in recovery rates were seen following the administration of human and porcine insulin for the treatment of DKA in a prospective trial with a small study population of people with both type 1 and type 2 diabetes (Ib).702

Continuation of insulin administration past the usual cut-off point of near-normoglycaemia versus conventional insulin regimen (rehydration, electrolyte replacement and insulin at 5 U per hour to near-normoglycaemia, that is blood glucose less than or equal to 10 mmol/litre, and then at a reduced rate until clinical recovery) in one small study, significantly increased the resolution of ketosis, measured as duration of elevated blood 3-hydroxybutyrate levels, and acidosis (Ib).776

Bicarbonate therapy

IV sodium bicarbonate therapy added to the treatment regimen for DKA was shown in a randomised trial with small sample size to increase recovery of arterial pH and bicarbonate levels in the first 2 hours, but did not effect pCO2 or blood glucose levels.248 All patients in the bicarbonate group developed hypokalaemia (Ib).

One study compared the effect of two different IV bicarbonate doses (adjusted to initial arterial pH) on the recovery rate of DKA, with placebo.514 No significant differences were seen between the groups treated with bicarbonate or placebo (Ib).

In agreement with these studies, one small trial showed that IV bicarbonate therapy had no additional beneficial effect when compared with standard DKA therapy without bicarbonate supplementation (IIa).756

No significant differences were seen after the addition of phosphate therapy to treatment for DKA in a small trial.229 A protective effect against hypophosphataemia was seen following phosphate treatment compared with placebo, but only on the first day of treatment (Ib).

An additional paper also reported no evidence of clinical benefit of phosphate therapy compared with placebo (Ib).781

Somatostatin therapy

One small study concluded that addition of the somatostatin analogue, octreotide, to low-dose insulin therapy reduced the time taken for correction of ketonuria.794 However, no such effect was seen on the recovery rate of hyperglycaemia and acidosis (Ib).

12.4.2. Health economic evidence [2004]

The health economic searches found only one US-based costing study.373 As such, no specific health economic guidance can be provided here.

12.4.3. Considerations [2004]

DKA management was noted to be based on a mixture of types of evidence, pathological, pharmacokinetic, clinical outcomes, cohorts and trials.

It was noted that DKA management is:

  • quite detailed
  • often performed under the supervision of diverse groups of specialists
  • dependent on careful monitoring if catastrophic outcome is to be avoided

There was broad consensus on issues of management, which largely seem to revolve around ameliorating the acidosis and hyperglycaemia without inducing the possibly fatal complications of cerebral oedema, hypokalaemia or aspiration pneumonia. Moderation in the speed and methods of correcting dehydration, hyperglycaemia and ketosis is combined with a high intensity of the monitoring of the changing condition of the patient.

The group noted that there was no evidence at all for the use of bicarbonate in any situation, and that the consensus recommendations for its use below a pH of 6.9 were poorly grounded in either clinical experience or any kind of evidence.

The group noted that the nature of insulin pharmacokinetics and pharmacodynamics suggested that the detailed studies of ways of starting insulin infusions had no logical basis.

Clinical experience of management in adults suggested that acute respiratory distress syndrome (‘fluid on the lung’) was seen not infrequently in addition to cerebral oedema. While the evidence that either of these could be ameliorated by using lower rates of saline replacement was not good, nor was there any impression that in the non-shocked patients such lower rates were harmful. Accordingly they are recommended.

Members of the group had seen examples of glucose concentration escape after reaching near-normal glucose levels, and felt that the evidence-based lesson of the Belfast paper (that these insulin-resistant patients require continued administration of higher rates of insulin than other patients on insulin infusions) was worth noting.776

12.5. Recommendations [2004]

103.

Professionals managing DKA in adultsshould be adequately trained, including regular updating, and be familiar with all aspects of its management which are associated with mortality and morbidity. These topics should include:

  • fluid balance
  • acidosis
  • cerebral oedema
  • electrolyte imbalance
  • disturbed interpretation of familiar diagnostic tests (white cell count, body temperature, ECG)
  • respiratory distress syndrome
  • cardiac abnormalities
  • precipitating causes
  • infection management, including opportunistic infections
  • gastroparesis
  • use of high dependency and intensive care units
  • recommendations 104 to 111 in this guideline.

Management of DKA in adults should be in line with local clinical governance. [2004]

104.

For primary fluid replacement in adults with DKA, use isotonic saline, not given too rapidly except in cases of circulatory collapse. [2004]

105.

Do not generally use bicarbonate in the management of DKA in adults. [2004, amended 2015]

106.

Give intravenous insulin by infusion to adults with DKA. [2004]

107.

In the management of DKA in adults, once the plasma glucose concentration has fallen to 10–15 mmol/litre, give glucose-containing fluids (not more than 2 litres in 24 hours) in order to allow continued infusion of insulin at a sufficient rate to clear ketones (for example, 6 units/hour monitored for effect). [2004, amended 2015]

108.

Begin potassium replacement early in DKA in adults, with frequent monitoring for the development of hypokalaemia. [2004]

109.

Do not generally use phosphate replacement in the management of DKA in adults. [2004, amended 2015]

110.

In adults with DKA whose conscious level is impaired, consideration should be given to inserting a nasogastric tube, monitoring urine production using a urinary catheter and giving heparin. [2004]

111.

To reduce the risk of catastrophic outcomes in adults with DKA, ensure that monitoring is continuous and that review covers all aspects of clinical management at frequent intervals. [2004, amended 2015]

Copyright © 2015 National Clinical Guideline Centre.
Bookshelf ID: NBK343337

Views

  • PubReader
  • Print View
  • Cite this Page
  • PDF version of this title (6.1M)

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...