DKA: Managing it the Welsh Way

An Update on Recent Changes

I used to be fairly ambivalent towards the All Wales Diabetic Ketoacidosis Integrated Care Pathway (DKA ICP).  It’s quite detailed (as it should be), quite prescriptive with lots of box ticking and number filling but at least it made life easier when faced with a child in DKA on a night shift, and you’re less likely to make mistakes (hopefully).  That ambivalence disappeared following a situation with a very sick child in DKA with no pathway or guideline, or even blood gas/U&Es for that matter! Granted, this situation I found myself in was a few thousand miles away in less than ideal settings, but knowing the underlying pathophysiology and principles of treatment that the pathway is based on without the usual resources I’m used to, saved us both (the patient and me!) and I will forever be grateful that I have such a life saving resource at my fingertips in my native UK clinical setting.

This latest blog post is written by Dr Chris Bidder (previously of the Dear Me fame), a consultant paediatrican, highlighting the general universal principals of managing a child in DKA and the changes to the new all Wales DKA pathway, based on the updated national guidelines.  Although specific to Wales, I would encourage you all to have a look, it’s quite useful for everyone but remember to use your own local guidance if you work outside of Wales; now over to you Dr Bidder:

The new pathway contains lots of changes that need your attention: this blog deliberately does not explain them all in detail and I’d encourage you to read the guideline carefully and ask any questions of your local diabetes team.  A pdf of the pathway is available from the CYP Wales Diabetes network (& Brecon group) website.

General principles:

  • DKA is a life threatening illness.  The pathway helps mitigate the risks, but does not replace frequent, careful reviews and the use of clinical judgement.

  • A slow correction of biochemistry is the target, over 24-48h, to reduce the risk of complications.

  • Guidelines occasionally need to be modified for individual patients.  Consult senior colleagues if you think this is necessary and record in the “Variance” section.

Key differences from the previous version are highlighted below with links to the relevant page in the pathway:

  1. More cautious initial fluid resuscitation (page 8).

  2. Use initial pH (not clinical judgement) to estimate dehydration (page 7).

  3. Significantly altered fluid calculations (page 8).  Please use the online calculator and check fluid calculations carefully.

  4. Lower starting dose of insulin (page 9).

  5. Emphasis on frequent clinical reviews (page 10) with direct guidance about when they should happen and what to record at each review.

  6. Highlights the importance of calculating corrected sodium (page 10) for every set of results and explains why this is necessary.

Other notable differences you should go through include an altered strategy for managing hypokalaemia that may occur during treatment, the use of bedside blood ketone testing, treating very mild DKA with oral fluids and sick day rules, additional guidance about neonatal DKA and hyperglycaemic hyperosmolar state plus advice about long acting insulin, pumps and switching to SC insulin.

By all means ask @drbidz on Twitter if you have questions your diabetes team can’t answer.

26/07/2016

*Important legal disclaimer.  The DKA ICP is for use only in Wales.  Use your local guidance*